BLD2020-0866+Side Sewer Application+11.17.2020_2.52.08_PMSIDE SEWER
PERMIT APPLICATION
CONTRACTOR INFORMATION:
Company Name: •H-J m Q b�eve� Pv
Company Address:
S02 92-1-J S-;� S'E
City: C Y-� re Zip: 5 8 2 6 8
State License # H o M E b D C&! Z "'), 0
Expiration Date: O f/ 09 2 v 2 2
PROPERTY INFORMATION:
Site Contact:
Phone #: q2 5- S 2 to I G
Email #: CI0.Ve . rtO laA 21`i @g.�-��; +_ C0
City Business License #
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Address: 1 1 —% q A s-.+. 5 W i E G 44 v illd' S 1�i 13 a 2 vO
Owner's Name: ^
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Phone #:
❑ FULL LINE REPLACEMENT SPOT REPAIR ❑ PIPE BURST ❑ RELINE (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. p
SIGNATURE VP DATE / 17 -Bolo
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE