SEWER APPLICATIONof E DAq p4/,
L J'
INC. 1 B90
CONTRACTOR INFORMATION:
SIDE SEWER
PERMIT APPLICATION
Company Name: � Site Contact:
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Company Address: 6 2 � & 5,ej Phone #:
City: Zip: Email #:
State License # .Tl m z m c� 7 / 8 City Business License #
Expiration Date:
PROPERTY INFORMATION:
Address:
Owner's Name:
Phone #:
❑ FULL LINE REPLACEMENT ❑ SPOT REPAIR ❑ PIPE BURST Q RELINE (PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific):
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.
RESU B
OCT 2 S 2019
BUILDING DEPARTMENT
CITY OF EDMONDS
SIGNATURE z�z. -0�°''1 ,/' DATE
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE