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CONTRACTOR INFORMATION:
SIDE SEWER
PERMIT APPLICATION
Company Name: kV w 4OM&-s " Site Contact: P)&,LWArVr AVM_
Company Address: po,�� 6-5-5413- Phone #: 2a4 S-1 ( 1-1-1 -7
City: tjeN--t7Z1t:r Zip: 4(sk 5s-
State License #
Expiration Date:
PROPERTY INFORMATION:
Email #:
City Business License #
Address: -/j D 15
Owner's Name: T kj o-& F(ey— LL e- i 3A t-W 4ur 4�A Li -K -
Phone #:
® FULL LINE REPLACEMENT ❑ SPOT REPAIR ❑ PIPE BURST ❑ RELINE (PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific):
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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 NE S EXPRESS PERMISSION TO PERFORM WORK ON THAT ADJACENT
PROPERTY.
SIGNATURE DATE
Contractor or A. n
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE