REVIEWED BLD2021-0235+SS APPLICATION+8.6.2021_5.41.50_PM+2344746v4� Of EE740 �
SIDE SEWER
PERMIT APPLICATION
CONTRACTOR INFORMATION:
Company Name:
Company Address. Z
City: tip:
State License # .
Expiration Date:
PROPERTY INFORMATION:
Address: Z ?j j2—q it -Av"jF
Owner's Name: , ; 1 / / V 19
Site Contact:
Phone#: -zo/ to 3 (f
Email#: I,
City Business License #
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Phone #: 1
-
❑ FULL LINE REPLACEMENT POT REPAIR ❑ PIPE BURST ❑ RELINE (PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific):
L,o�r l - .1dw c��►�-tr��an . �r 210 sr >--/
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
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
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