Side Sewer Applicationpf EDANoHv4 �Nc. 1Sq�
CONTRACTOR INFORMATION:
Company Name:
SIDE SEWER
PERMIT APPLICATION
Company Address II_
/ ! Z 20
c� y` r%i0it1Q4� �� zip:9�oZ0
State License #
Expiration Date: f':
PROPERTY INFORMATION:
Site Contact: DAot-WIta
Phone #:
Email#: �f. �S��rfJAo� �'.aLVI
City Business License #
4( A 55 1p too 5 O(o8�
;RLFIJLL LINE REPLACEMENT ❑ SPOT REPAIR ❑//PIPE BURST ❑ RELINE (PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific): /�iL(JS11 c�
a14
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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 PROPERT r, I HAVE RS EXPRESS PERMISSION TO PERFORM WORK ON TIIAT ADJACENT
PROPERTY.
SIGNATURE fW1/C DATE
Cohrractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE