REVIEWED BLD2021-0812+SS APP+10.18.2021_11.11.12_AM+2468372tJ~�y Of EDA404,
j'uC. 1890
CONTRACTOR INFORMATION:
SIDE SEWER
PERMIT APPLICATION
Company Name: oc-40W 40M&--S UZ Site Contact: *0 h LU1A Vr 40�_
Company Address: 1'.oao< s-T54ig- Phone #: 2106 15-1 ( 111 -Z
City: 'je4-i rce- Zip: ,is k ss-
State License #
Expiration Date:
PROPERTY INFORMATION:
Email #:
City Business License #
Address: 1,q 0j
Owner's Name: —F(j'&s Fl E 2 ' / G ' �AL f _(� r � I ✓
Phone #: !'f• WCY �►ri l�l...f�
® FULL LINE REPLACEMENT ❑ SPOT REPAIR ❑ PIPE BURST ❑ RELINE (PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific):
14-&v,9,& oil
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 qAVE NE S EXPRESS PERMISSION TO PERFORM WORK ON THAT ADJACENT
PROPERTY. //
SIGNATURE DATE (0 4
Contractor or A n
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE