REVIEWED BLD2021-0809+SS APP+10.18.2021_11.04.55_AM+2468348OF EDAfo41
W-c. I s90
CONTRACTOR INFORMATION:
SIDE SEWER
PERMIT APPLICATION
Company Name: OVoiyM , t 0M&,S UZ Site Contact:
Company Address: p-0-� s—S-54.s Phone #: 2ae
City: �jC�. ti2.� Zip: list
State License #
Expiration Date:
PROPERTY INFORMATION:
Email #:
City Business License #
Address: -Iq 03 �
Owner's Name: T I (' r Ft F� r' G
- (,� +'V+
Phone #:
® FULL LINE REPLACEMENT ❑ SPOT REPAIR ❑ PIPE BURST ❑ RELINE (PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific):
#Jew
1-t&0645- of
i �t54�
ISSUANCE OF THIS PERMIT DOES NOT CONSTITUTE PERMISSION TO WORK ON ANY P)OPERTY 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 WA NT TO CITY OF EDMONDS, IF REPAIR OF EXISTING SEWER EXTENDS TO AN
ADJACENT PROPERT , 1 AVE NE tS EXPRESS PERMISSION TO PERFORM WORK ON THAT ADJACENT
PROPERTY. / ne
SIGNATURE DATE (® K
Contractor or A n
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE -