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21707 98TH AVE W
APPLICATION
:X., -,i, � I
for
The City of Edmonds SEDE SEWER PERYaT
NEW CONSTRUCTION E] REPAIRS EASEMENT No . ..........................................
109-00750
OWNER ............ �.14.qp.us .... B....,.Ja.co.b.s-en ................................................... CONTRACTOR ............... .................
.... ..... . .. .... ................................................................. PERMIT No . ......................
ADDRESS ........ Z1.70.7 ... ..... 9 81b ... A.ye ...... 14 ................................................
0
LEGAL DESCRIPTION: LOT No . .............................................. BLOCK No . ............................................
NAMEOF ADDITION .............................................................................
Dye Tested On Sewer 1972
Approved:
DATE................................................ By ......................................................................
#P20 CA File No:
Critical Areas Checklist
Site Information (soils/ topography/hydrology/vegetation)
7", /,
1.. Site Address/ Location: 7-1 -7 0-7
2. Property Tax.Account Number: -7 0 2- 00.,�-O 0
#P20
Pate Received: G-1c(70S.
City Receipt
Critical Areai File#:
...Critical Areas Checklist Fee:—$135.00
Date Mailed to Applicant- L
CRITICAL AREAS
CHECKLIST
on s orm. t
ne Critical Areas�Chec;Mjst contained ;thi f is o
A pr histh
y. owner, or er authorized
opert representative,
be filled � out :by, any.. person preparing. a... Development
musf.fill � out the ehecklis� sign%and.date it", submit it
1.
Tennit: Applicati on fo r the bnd�prior to::
City of Edn?
to th e City., The Ci t y will review the ch&klist�: mak I e
a
Jiis/her submittal of the'.appli 'onlotheCity.
icati
�._,precursory site visit� and.. mAd A determination � of the
The,purpose-Of the, a6cklist.11,
sj ena c:�City staff 46
.134b.sNuerit stebs :necessary.. lete.4 development
*U�e 'whether any.potential: Critical Areas'. are or
permit Application.
n*y bej:presenj onthe suT Th
bjeqtprqperty,,:� eiii b�mation'
�:Please su mi ...icim.....map, a prigyn the sign,
ed copy
needed ' to �qqmplete e� Ch., Idi
ec ist h
m fh din
f this form. to at�ist, Ci it�aff and locating the
..4 e observations, i 6ta.:available,
o e si 6 or.
c described on. this. form
of: p.r erty M
City. Hall.jc-riti ��.areas myeft tqqes� joaps soil.,
addition'. the applicant.: shall include, other.:. pertinent
surveys
11 ormation (e.g., site . plan,. topography map, etc.) or
s es in copjunc on4i
itudi ti iffi" to assistant staff
.,..:m,comp1 th
e"g, . eir Pre immarv: assessment of the site.
The undersigned applicant- ai id �:
hiAer/its-heft d ti
-sj� afid;anigi in: con�i .4ffi of the appli ati6n, agrees
-M, on -pp.: e processing
an, o
�:,464eleasd,� mdetmi�.... e ilend af ld% thd� City..'6f Edinonds llarmless:66m� any an d., all: dAm�a s mc u g, rea
I din
ge sonable
b b d 'in hoe or. part
�Iatt.omey:s,.� maccurate or.
ase
"Tg fr n, of upon t4jw, ihislea din 9.
oniple ififormatidn::16.ii b q, �app his/hernistagotits premployee&
ished y th licant
B �sigi�4 th iht6 6ii:an txhibits herewilh:submitted are true and. correct to the best of my,.
y�my
kdowledge and thaff th e� I I bthalfof the- . owner as -listed belo'w��
am.au onze to 6 s a� ication on the
SIGNATURE OF APP LUCAINVAG
DATE
Property own Is
er -AnthorizAtionz
BY MY signature, I certi v that, I I hAV64k the above Applic antfAgent to apply fOr the stibJect landuse application
and grant my:perrnissfion. forthe POlid.offibiils%i�4,,t�h�ie.gitiff,.of the:Cit�:of 186i6ndsiio'� 96- t t
jec property, dr.thi
purposes of inspection and sting att,e.n. -this-a, 1311, fion
po., dantloi F
SIGNATURE OF OVVNER
DATE�
PLEASE PRINT
CLEARLY
Owner/Appficant.
�ppjcant Representative.
0. 464, A4 i!5�1 e.:.. iq, 6�
A -vp ((coLA
Name
'714
Name
1 7 0 2, P, A
Street Address
Street Address
121n 4 A/), 2_
kA 1.0-7 —5013Z,
city State Zip
city State zip
Telephone: 425 7 7) - -3 3 3 2- Telephone:
Email address (optional): Email Address (optional):