REVIEWED BLD2021-0009+side sewer app+6.8.2021_12.55.18_PM+2238195REVIEWED BY
ENGINEERING
SIDE SEWER
PERMIT APPLICATION
CONTRACTOR INFORMATION:
Company Name: Select Homes, Inc.
Company Address: 16531 13th Ave W. Ste. A107
City: Lynnwood Zip: 98037
State License # SELECH1110KN
Expiration Date: 12 31 21
PROPERTY INFORMATION:
Address: ffWaln ut St. Edmonds, WA 98020
Owner's Name:
Select Homes, Inc.
Phone #: 427.742.6044
Site Contact: Gary Klick
Phone #: 206.730.0670
Email #: gary@selecthomeswa.com
City Business License # NR-026591
❑ 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.
SIGNATUREAz / `"'` DATE 6.8.21
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE