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17808 73RD PL W
#P20
'QC_ I %19�
City. of Edmonds
Development Services Department
Planning Division
Phone: 425.771.0220
Fax: 425.771.0221
W
Date Received:, a)11�4��aus
City Receipt #: Z:2 Z51
Critical Areas File#:
Critical Areas Checklist Fee:: $135.00
Date Mailed to Applicant -
The Critical Areas Checklist contained on this form is to A property owner, or histher.aut onze representative, -
be filled out by any person preparing a Development must fill out. the checklist,. sign I and date it, and submit it.
Permit Application for the City. of Edmonds prior to to the City. The City will reviewAhe 'checklist, make a
-his/her submittal of thb-*appli�afion to *the 'City. pprecursory site visit,, and make a, determination o'd the
subsequent ste mplete a development
,ps necessary to,co
the purpose of the Checklist is to enable City staff, to
determine whether any potential Critical Areas are, or Perrmi application.
may be, present on the subject property. The inforination Please submit a vicinity map, along with the signed copy,
needed to complete the Checklist should be - easily. of -this form to assigt. City staff in finding and locating the
available from observations of the site or data available at specific piece . of property, described 'on . this form.. In
City Hall (Critical areas inventories, maps, 'or soil addition, the. applicant.' shall include other pertinent
opo h" , etc.) or
surveys). information (e.g. site '01an'. iii grap y map
studies in conjunction with this Checklist to assistant staff
in completing their prplimi*iiary assessme nt of the site.
The undersigned applicant, and his/her/its heirs,. and assigns,:in consideration on. the processing of the applic' ation agrees
.to release, indemnify, defend and hold the City.of Edmonds harmless from any and all damages, including reasonable
attorney's fees, arising from any action or infraction based in whole or part upon false, misleading inaccurate o ;7._-*,-.'.,-_*,
incomplete information furnished by the. applicant, his/her/its agents or employees.
ni� 'signature, J ceftif� that the information and exhibits herewith submitted are true and 'correct to the best'of my
66wledge and that I am authbrized to file this app�ication o� the behalf of the owner as listed b�low...
SIGNATURE 0FAPPLICA:N+/AdiNT DATE 0
Property Owner's Authorization
�y my signature, I certify that I have authorized the above Applicaht/Agent-to apply for the'subject'land,use application,
a�d grant my permission for the public officials and the staff of the City of Edmonds to . enter the subject property for the
Purposes of inspection and pooin dat to �this application.
g atten
SIGNATURE OF 0 DATE
Owner/Appficant: Applicant Representative:
Name
S treet Address Street Address
962-L
6 -WA
city State city State zip
17-ip
-7
Telepho,
ne: Telephone:
Email address (optional) MI Email Address (optional):
comca5r ri
0 A
#P20
Critical'Areas Checklist
Site Information (soils/ topography/ hydrology/vegeta ori)
1. Site Address/ Location: I
CA File No:.05---14 I
Z
2. Property TaxAccount. Number: 004139'00QCQC�00
3. Approximate Site Size (acres or square feet): PERMIT COUNTER
4. Is this site currently developed? yes; no.
If yes; how is. site developed?. PbU _5e, a raiij P_ LLO'I'M 1y) n!�N Poo I
5. Describe the general site topography. Check all that apply.
Flat less than 5-feet elevation change over entire site.
7.
8.
Site contains areas of seasonal standing water:
What season(s) of the year?
Site is in the floodway
Rolling: slopes on site ;generally -less than - 15 % (a vertical rise of 10-feet over a horizontal
distance of 66-feet).
Hilly: slopes presenton site of more than 15% and less than 30% (a vertical rise of 10-feet
over. a horizontal distance of 33 to 66-feet).
Steep: grades of greater than 30% present on site (a vertical rise of 10-feet over a horizontal
distance of less than 33-feet).
Other (please describe):
Site contains areas of year-round standing water: Approx. Depth:
;Approx.Depth: Z%� )a
r
U)6rtj?k � s. i
floodplain . of a water course.
,9. Site contains a creek or an area where water flows across the grounds surface? Flows are year-round?
Flows are seasonal? - (What time of year?
10. Site is primarily: forested meadow ;shrubs' mixed
urban landscaped QaNyn, shrubs etc) _X
11. Obvious wetland is present on site:
For City Staff Use Only
1. Plan Check Number, if applicable? t-A 0 Yle, !2 i VeYl
2. Site is Zoned? P- S
3. SCS mapped soil type(s)? 67- A1A,&VVVDD4 LAv1Q0LV1 101nd WVIAR[f4� 2-- 9'/- -!�i I Q Qe- 5
JE52,�Fy- 'ic)
A-1(jFAAA./D0C1 C1V'AV-fAtU A0YI&A ID0,Y0 1,1;-)
j 'A Exp co i UYI h a 7a rd"-
4. Critical Areas mventory or C.A. map indicates Critical Area on site?
Site within designated earth. subsidence landslide hazard area?. NO - VOLAt 1�)U� k A \'V) (4
O�f� Cf a I t-D M A -H rl CA I J ftcvvivi M at on
DETERMINATION
STUDY REQUIRED X WAIVER
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