SIDE SEWER APPLICATIONOF f OkFaM
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CONTRACTOR INFORMATION:
Company Name: y
SIDE SEVER
PERMIT APPLICATION
Company Address: j
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Site Contact:
Phone #: ?-,10 41,1-
City:0,Mho (►'1 i Zip: gY101( Email #:� UY1CS � Office (�Arr�a �.l• W rK
State License # �a City Business License # _ —
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PROPERTY INFORMATION:
Address:
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Owner' Name:
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Phone #: c; Q _�cxr_
❑ 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.
SIGNATURE 3 DATE 7A
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE