BLD2021-0645+SS APP+7.21.2021_1.39.58_PM+2313734REVIEWED BY
ENGINEERING
SIDE SEWER
PERMIT APPLICATION
CONTRACTOR INFORMATION:
Company Name: Select Homes, Inc.
Site Contact: Gary Klick
Company Address: 8304 212th St. SW
Phone #: 206.730.0670
City: Edmonds Zip: 98026
Email #: gary@selecthomeswa.com
State License # SELECH1110KN
City Business License # NR-026591
Expiration Date: 12 31 21
PROPERTY INFORMATION:
Address: E00 Walnut St. Edmonds, WA 98020
Owner's Name:
Select Homes, Inc.
Phone #: 427.742.6044
❑ FULL LINE REPLACEMENT ❑ SPOT REPAIR
❑ PIPE BURST ❑ RELINE (PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific):
Connect to new sewer stub
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 DATE 7.8.21
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE