ENG2024-0123+City_Application+2.29.2024_12.55.15_PM+4092969SIDE SEWER
PERMIT APPLICATION
CONTRACTOR INFORMATION:
Company Name: TBD Site Contact: TBD
Company Address: Phone #:
City: Zip: Email #:
State License # City Business License #
Expiration Date:
PROPERTY INFORMATION:
Address: 8503 200th St SW Edmonds, WA 98026
Owner's Name:
Signature Homes by Village Life, LLC
Phone #:
DULL LINE REPLACEMENT SPOT REPAIR []PIPE BURST RELINE (PERMALINE ONLY)
DESCRIPTION OF PROPOSED WORK (Be Specific): Connecting new home to existing sewer.
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 EXPRESS PERMISSION TO PERFORM WORK ON THAT ADJACENT
PROPERTY.
ly signed by Ausbn AMerson
Austin Anderso ' 20240 ;11;;23�8 =oC 1 1/31/2024
SIGNATURE DATE
Contractor or Agent
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE