ENG2022-0523+City_Application+10.22.2022_2.30.13_PM+3179906CONTRACTOR INFORMATION:
Company Name:
Company Address:
City:
State License #
Expiration Date:
PROPERTY INFORMATION:
SIDE SEWER
PERMIT APPLICATION
Site Contact:
Phone #:
Zip: Email #:
City Business License #
Address: 7527 172nd St SW, Edmonds, WA 98026
Owner's Name:
Kaveh Noorbakhsh
Phone #:
DULL LINE REPLACEMENT SPOT REPAIR []PIPE BURST RELINE (PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific): Addition to existing building , new clean out will need to be
added on north of the new addition kitchen.
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 10/21 /2022
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE