ENG2024-0252 CITY SIDE SEWER PERMIT APPLICATIONSIDE SEWER
PERMIT APPLICATION
CONTRACTOR INFORMATION:
Company Name: Site Contact�����
Company Address: Phone #:
City: Zip: Email #:
State License # City Business License #
Expiration Date:
PROPERTY INFORMATION:
Address:
Owner's Name: hl,� ex tin c?k U
Phone #: ?40r ��15 cg'lrd
FULL LINE REPLACEMENT'OPOT REPAIR []PIPE BURST RELINE (PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific): A -00 cktOOO LIT APp P<-L--0C-PJr
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 ERS EXPRESS PERMISSION TO PERFORM WORK ON THAT ADJACENT
PROPERTY.
SIGNATUR DATE S 2 Z
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE