ENG SEWER APPLICATIONSIDE SEWER
PERMIT APPLICATION
CONTRACTOR 1NFOR141ATION•
Company°Name: L ., }iris \ 5,
,.V Site Contact:
Company Address: L/va -0 4 ` 5 A-- Phone #:
City: SvwVw�r�, Si.. Zip: o
State License M-rTeS £%IC
Expiration Date: � _
PROPERTY INFORMATION:
Email#: l,y7GC� 4 c"-'P%
City Business License #
Address: 537
5 ""-' Arse., S t,,..,.,4- 9 �; oa o
Owner's Name: _
I re L) U-Y,- Rc fie_
Phone #:
❑ FULL LINE REPLACEMENT VSPOT REPAIR
DESCRIPTION OF PROPOSED WORK (Be Specific):
❑ PIPE BURST ❑ RELINE (PERMALINE ONLY)
5' i�x.t � c✓\ S
ISSUANCE OF THIS PERMIT DOES NOT CONSTITUTE PERMISSION TO WORK ON ANY PROPERTY OTHER
THAN THAT OWNED BY THE SUBJECT PROPERTY OWNER.
CERTIFICATIONS NECESSARY FOR INSTALLATION METHODS ARE THE RESPONSIBILITY OF THE
CONTRACTOR PERFORMING SAID WORK
I REPRESENT AND WARRANT TO THE CITY OF EDMONDS, IF REPAIR OF EXISTING SEWER EXTENDS TO AN
ADJACENT PROPERTY, I HAVE OWNERS EXPRESS PERMISSION TO PERFORM WORK ON THAT ADJACENT
PROPERTY.
SIGNATURE I "'t; , DATE
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE