REVIEWED ENG BLD2020-0865+side sewer app+1.5.2021_2.25.12_PM+1974767RESUE,
BLD2020-0865
Jan 28 2021
CITY OF EDMONDS
DEVELOPMENT SERVICES
DEPARTMENT
SIDE SEWER
PERMIT APPLICATION
CONTRACTOR INFORMATION:
Company Name: L,(_, �D Site Contact:
Company Address: '! L Phone #:
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City- zip: Email #: �Gt i -C( ��(� �(iL
State License # � (� � l- R i tif4 City business Liceme # l� � Oro
Expiration Date:
PROPERTY INFORNIAT'ION:
Address: C`
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Owner's Nance:—
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❑ ► tii.,L L,fNf: RF I'1.,10E di6\"T" ❑ SPO"T' t{EP,iIIt ❑ 11111F: BURST ❑ RELINE (PE RNIAL.INE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific):
- Sewer tap tA-be-completed_un.d.Pr -hart neat T...is-permit _....._..__._._.._..._..__ _._._
.............
is for connection to the sewer stub installed under the short plat to the structure. - J.Lambert - City of Edmonds _
ISSUANCE OI- 'rFIIS PERMIT DOES NOT CONSTITUT I'7 PERMISSION TO WORK. ON ANY PRCIPE RTY 0 l il'.It
THAN THAT OWNED BY THE SU13JEC'T PROPERTY OWNER.
CERTIFICATIONS NECLiSSAItY [-'Oil INSTALLATION MI:TITODS All 1.-'1-Iik RI SPONSIBIL1'I'Y 01''rll1::
CONT[UNCTOR PERFORMING SAIL) WORK.
I REPRESENT AND WARRANT 'TO TI Ili CITY OF EDMONDS. 117 REPAIR OF EXISTING SEWER EXTENDS TO AN
ADJACENT PROPERTY, i HAVE OWNERS EXPRFSS PERMISSION TO PERFORM WORK ON THATADJACENT
PROf' ERTY.
SIGNATURE l/ DATE'
Con star or a cnl
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE: