ENG2024-0175+City_Application+4.18.2024_12.22.02_PM+4205226CONTRACTOR INFORMATION:
Company Name:
Company Address:
City:
State License #
Expiration Date:
PROPERTY INFORMATION:
SIDE SEWER
PERMIT APPLICATION
Site Contact:
Phone #:
Zip: Email #:
Address` 19803 81 st PI W-Edmonds
Owner's Name: James Rust-206-571-2279
Phone #:
City Business License #
W�ULL LINE REPLACEMENT SPOT REPAIR []PIPE BURST RELINE (PERMALINE ONLY)
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', DESCRIPTION OF PROPOSED WORK (Be Specific): Relocate existing side sewer due to proposed SFR addition
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 4/18/24
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE