ENG2022-0446+City_Application+9.2.2022_11.04.48_AM+3088178SIDE SEWER
PERMIT APPLICATION
CONTRACTOR INFORMATION:
Company Name: Built By Design WA INC Site Contact: Dave Peterson
Company Address: 2114 120th PL SW #B
2114 120th PL SW #B
City: Everett Zip:98204
State License # BUILTDW781 KL
Expiration Date: 5/16/2024
PROPERTY INFORMATION:
Address: 19637 80th PL W
Owner's Name:
Wes &Sara Lang
Phone #:
Phone #: 425.327.4529
Email": davebbd1960@gmail.com
City Business License # 603603705
FULL LINE REPLACEMENT POT REPAIR []PIPE BURST RELINE (PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific): Install New Side Sewer Lateral Cleanout outside of new addition.
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.
Digitally signed by Tuvia Poliskin
SIGNATURE T u v i a P o l i s k i n Date: 2022.09.02 10:55:26-07'00'
Contractor or Agent
DATE 09.02.22
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE