ENG2023-0617+SEWER City_Application+11.30.2023_12.47.02_PM+3926768OF E D tjoyv
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CONTRACTOR INFORMATION:
SIDE SEWER
PERMIT APPLICATION
Company Name: v A94y
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Site Contact: M) 1.
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Company Address: t' 5 -72chL2G7-
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Phone #: 4z'—
-306
_ 15 7-70
City::5A)a-,Ae) iMl Q -, W 4 Zip: 17 &290
State License # �+ C L clI.41C0
Expiration Date: �-^ Z_aZ��
PROPERTY INFORMATION:
Email #:
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City Business License #
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Address: a �f� �� r�4'--�
Owner's Name: lQUi4A/ --4 5c1 D A f 01 C' /i
Phone #: 4I 3�^��
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GULL LINE REPLACEMENT DPOT 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 WARRANT TO THE CITY OF EDMONDS, IF REPAIR OF EXISTING SEWER EXTENDS TO AN
ADJACENT PROPERTY, I HAVE OWNERS XPRESS PERMISSION TO PERFORM WORK ON THAT ADJACENT
PROPERTY.
SIGNATURE — i.'li, ' DATE 11127 0124,;2—
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE