20160111101455.pdfSIDE SEWER
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PERMIT APPLICATION
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CONTRACTOR INFORMATION:
Company Name �� LUSite Contact: E
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State License #
Expiration Date:
Email #:
City Business License # CO
PROPERTY_ INFORMATION:
Address:
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Owner's Name:
Phone #: ;-00 /-N -7U-7--1
❑ FULL LINE REPLACEMENT . SPOT REPAIR ❑ PIPE BURST ❑ RELINE (PERMALINE ONLY)
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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 EXPRESS 1?'ERMISSIO TO PERFORM WORK ON THAT ADJACENT
PROPERTY
SIGNATUREAll
DATE
Contractor or Agent
1 /4
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE