REVIEWED Sewer Availability Form+1.24.2022_11.01.39_PM+2638858Of EV'tJo�0
A
INC. l 3aa
SECTION A
SEWER AVAILABILITY APPLICATION
Complete and submit this form through�v�v.VI,yBuildingPerrnit.coni.
Applicant Inforination
Contact/Applicant Name ! I cil k !1 As
Phone Number. 4 Z S, Zy r 3
Email r,� LQy 1 a Z S ✓Z v ` s
Address I PL Gas
City I/ M 40 S State w4 Zip t�gQGn
Project Name V A 14 V 1 L 9 k l W S F
Associated Permit Number
Address I j C' t P
City D MO %l/n � State ttiA I Zip qg a 0&/,
Parcel No. O i O l 4 3 0 V 00 t2 00
Does the property currently have sewer service? ❑ Yes (City of Edmonds sewer) o
Describe project (number of buildings, number of units, number of stories per building):
NEW SFR
In what phase is the project?
Design Review ❑ Building Permit
❑ Preliminary Plat ❑ Rezone or Other
Associated permit application number(s), if applicable:
SECTION B
dApplicant certifies that this project is a single-family residence, multi -family project of four units or
less, or short plat subdivision (four single-family lots or less), in which case completion of a full utility
availability study shall not be required. Please sign below and submit this form through
,www. MyBuildingPernut. coin.
❑ For all other permit types, a utility availability study
submit the complete application tlyrpug4 ,,yw .MvBttild
APPLICANT SIGNA
APPLICANT PRINTED NAME: i/ �( G fi e p 4
and associated fees will be due. Please
DATE: 1Z 28/2�
VA rsVIZA
Form Updated 12/9/2021