ENG2023-0639+City_Application+12.20.2023_12.23.19_PM+3964307SIDE SEWER
PERMIT APPLICATION
CONTRACTOR INFORMATION:
Company Name:
Company Address:
City: Zip:
State License # SELECH 1110KN
Expiration Date:
PROPERTY INFORMATION:
Address: 22212 98th Ave W
Owner's Name:
Select Homes, Inc.
Phone #:
Site Contact: Gary Klick
Phone #:
Email #:
City Business License #
DULL LINE REPLACEMENT DPOT REPAIR []PIPE BURST RELINE (PERMALINE ONLY)
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
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE