Side Sewer Permit ApplicationSIDE SEWER
PERMIT APPLICATION
CONTRACTOR INFORMATION:
Company Name: isI&- 17 &ACAwq&� Site Contact: cpAl- 40-u—
Company Address: 5r2 L- i 4C Phone #: 0,7 - 2 39 +,tcl
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City: Zip: Email #: 1'� e G �flp CEyr�
State License # N.* IT EL qq 9
Expiration Date:
PROPERTY INFORMATION:
Address:
Owner's Name:
Phone #: 114.( - 03 05-
City Business Lix cens
,FULL LINE REPLACEMENT ❑ SPOT REPAIR ❑ PIPE BURST ❑ RELINE (PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific): d-#,.P iE.,z1sn" bras Tb ri� . 4_ g5c-
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 51142iff)
tpr o e `tom'
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE