Side Sewer Applicationr;
SIDE SEWER
PERMIT APPLICATION
's+c: Ya'Io
CONTRACTOR INFORMATION:
Company Name: tI S7• �, y�I�lc C Site Contact: Z7"Psl
Company Address: ! '?T�'�" Phone
#: �� yr q,//dL� /
C y'
/Z 2oZ A [ ,L/ t
�T Zip: 0 Email#: �T O�GZOI �.m4Pl
State License #� L8 J City Business License #
Expiration Date:
PROPERTY INFORMATION: �J "
Address: 3z- ?-
Owner's Name:
GtfG
Phone #:
/j[��',�FULL LINE REPLACEMENT ❑SPOT REPAIR EI PIPE BURST El RELINE (PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific): / 1 I
l�?r�/;Vf c fL IIIG
Cz—
ISSUANCE OF TFUS 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 PROPER , I HARS EXPRESS PERMISSION TO PERFORM WORK ON THAT ADJACENT
PROPERTY.
SIGNATURE VE DATE Z
Co rector or AgentAaAt
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE