Sewer Permit Application 806 Cary Rd - contractor for linerSIDE SEWER
PERMIT APPLICATION
CONTRACTOR INFORMATION:
Company Name: Site Contact.
�u✓z� Vfievldlt� (LG Scn4-I- �tt-s»'1
Company Address: .1�a.,tl; VI qq Phone#: 'p6-1R—<Sci lf.
City: W\Dvt �S �JZip` 9 c Email #: �+�a(a� SriwafFr�r+bl . COW
State License # C _]lq�swo City Business License # P)L_
Expiration Date: X` lA l l.W,
PROPERTY INFORMATION:
Address: Kne Cafe 9u
Owner's Name:
Phone#: �- *L'�—sO Ci4"�ly.i
❑ FULL LINE REPLACEMENT ❑ SPOT REPAIR ❑ PIPE BURST RRELtNE (PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific): (�
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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 c��� '�7/// DATE
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE