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PERMIT APPLICATION
N:
omes LLC Site contact: Balwant Aulck
CONTRACTOR INFORM
Company Name: Quantum
Company Address: 1226 169t
PI SW Phone
#:206-571-7777
#: balwantauick@gmaii.com
License #
1226 169th PI SW
city: Lynnwood
zip:98037 Email
State License # QUANT
8
6BW CityBusiness
Expiration Date: 02-05-2
PROPERTY INFORMATI
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Address: 7907 240th
Owner's Name: Twin Pi
LC - Balwant Aulck
Phone #:
[JULL LINE REPLACE
I IE
T DPOT REPAIR ❑PIPI
BURST RELINE (PERMALINE ONLY)
DESCRIPTION OF PROP
E
WORK (Be Specific):
New connection to Cit
y
tem
ISSUANCE OF THIS PE
OES NOT CONSTITUTE PERMISSION
TO WORK ON ANY PROPERTY OTHER
THAN THAT OWNED BY
E
SUBJECT PROPERTY OWNER.
CERTIFICATIONS NECESS
LRYFOR
INSTALLATION METHODS
ARE THE RESPONSIBILITY OF THE
CONTRACTOR PERFORM
G
SAID WORK.
I REPRESENT AND WA
TO TH CITY OF EDMONDS, IF
PAIR OF EXISTING SEWER EXTENDS TO AN
ADJACENT PROPERTY
O ELSEXP7RES:ISSIQN
TO PERFORM WORK ON THAT ADJACENT
PROPERTY.
2
SIGNATURE
DATE
tr
ctor oicse
C
NO
WORK SHALL BEGIN PRIOR To
PERMIT ISSUANCE