DNS REVIEWED BLD2021-0810+Side Sewer Application+9.22.2021_1.52.30_PM+2423278yN 4n
RECEIVED
9/24/21 BLD2021-0810
CITY OFEDMONDS SIDE SEWER
SERVICESDEVELDEW/1IT APPLICATION
CONTRACTOR INFORMATION:
Company Name: OU40yM , 10M&-s " Site Contact: W k(�UJA Vr AV�
Company Address: P-0-� s-554-s- Phone #: 24-4 -T
City: -jC?4' jTL,F"
State License #
Expiration Date:
PROPERTY INFORMATION:
Zip: -(Sk s-s- Email #:
Address: —1/j 01 n ,LO 44. �
��ll _y'T �L � Y�
City Business License #
Owner's Name: I�( U 3A.`IA"r
Phone #: `7
® FULL LINE REPLACEMENT ❑ SPOT REPAIR ❑ PIPE BURST ❑ RELINE (PERMALINE ONLY)
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DESCRIPTION OF PROPOSED WORK (Be Specific):
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 WA NT TO CITY OF EDMONDS, IF REPAIR OF EXISTING SEWER EXTENDS TO AN
ADJACENT PROPERT , I AVE (/WNEltS EXPRESS PERMISSION TO PERFORM WORK ON THAT ADJACENT
PROPERTY. / �e
SIGNATURE DATE (� K
Contractor or A n
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE