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SIDE SEWER
PERMIT APPLICATION
CONT10C OR INFOWNIA'1'ION:
Company Name: � r, f Site Contact: David Harris
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Company Address: LAC- Phone #: 206-795-2009
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City: S h ore-/i n � Lip' W Email #: harris.davidm@hotmail.com
State License # bAY L 144 L Ot 3 G Q 6 City Business License #
Expiration Datc: I % ` ..,�C� Z/
PROPER'I'Y INFORMATION:
Address:
21022 74th Ave W, Edmonds We, 98026
Owner's Name:
David Harris
Phone #: 9Q" ZO(o —7q S 2,.Do
® FULL LINE REPLACEMENT ❑ SPOT REPAIR ❑ PIPE BURST ❑ RELINE (PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific):
The proposed project Is to Install a cleanout at the ROW line along the existing sewer connection. The sewer stub is then to be extended from the
new cleanout to the proposed duplex.
ISSUANCE OF THIS PERMIT DOES NOT CONSTITUTE PERMISSION TO WORK ON ANY PROPERTY OTHER
THAN TILAT OWNED BY THE SUBJECT PROPERTY OWNER.
CERTIFICATIONS NECESSARY FOR INSTALLATION MF,TFIODS ARE THE RESPONSIBILITY OF T14E
CONTRACTOR PERFORMING SAID WORK.
I REPRESENT AND WARRANT TO THE CITY OF EDMONDS, IF REPAIR OF EXISTING SEWER EXTENDS TO AN
ADJACENT PROPERTY, 1 HAVE OWNERS EXPRESS PERMISSION TO PERFORM WORK ON THAT ADJACENT
PROPERTY, `, r
SIGNATURE.O' `rf�/L+--b DATE s `' hoe
Contractor or Agent
NO WORK SHALT, BEGIN PRIOR TO PERN11T ISSUANCE