ENG2024-0289+City_Application+6.11.2024_3.34.43_PM+4315629SIDE SEWER
PERMIT APPLICATION
CONTRACTOR INFORMATION:
Company Name: TBD Site Contact: TBD
Company Address: Phone #:
City: Zip: Email #:
State License # City Business License #
Expiration Date:
PROPERTY INFORMATION:
Address: 17606 72nd Ave W
Owner's Name:
Signature Homes by Village Life, LLC
Phone #:
DULL LINE REPLACEMENT SPOT REPAIR []PIPE BURST RELINE (PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific): Connecting new home to existing side sewer stub.
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.
ly signed by Ausbn AMerson
AustinAnderso 2024.05�33111f0W58-0 iQDC=vi0001,DC--C
SIGNATURE cDATE
a� 5/31/2024
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE