BLD2021-0094-Sewer Availability Application-11.23.2021<( Of EV tfo4/ �
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SECTION A
SEWER AVAILABILITY APPLICATION
Complete and submit this form to EngineeringPermitsPedmondswa.gov
Applicant Information
Contact/Applicant Name
Phone Number _'�W' i ►
���X9
Address
1,571
ME —
/ ME
Property
Project Name /L!
Associated Permit Number
Address 3szv
City f
State
Zip
v
Parcel No. / b� A9 p
Does the property currently have sewer service? &Yes (City of Edmonds sewer) ❑ No
Describe ]project (nuniber of buildings number of units, number of stories per buildin ):
In what phase is the project?
❑ Design Review A Building Permit
❑ Preliminary Plat ❑ Rezone or Other
Associated permit application number(s), if applicable:
SECTION B
pplicant certifies that this project is a single-family residence or short plat subdivision (four lots or
less), in which case completion of a full utility availability study shall not be required. Please sign below
and submit this form to EngineeringPermits@edmondswa.gov.
❑ For all other permit types, a u
submit the complete applicatioiy�f
APPLICANT SIG
APPLICANT PRINTED NAME:
study is required and associated fees will be due. Please
DATE: �` �v
Form Updated 09/02/2021