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22124 93RD PL W
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CONDrrfONAL WAIVER
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ib&� 0 -3 0 C-f
iint Ndri
perty':
Approxid'ia1d' Ite Si7,6 (acies or squne eet
S
4 es; no.
"U this'site, Pod?
curren
3 1
if y'es; how. site developed?_'� Lj
Describe t e gerwal-site h Clieck all *i� a
5. "gral? YN., �"y
I .11essthan 54,ekig dka�Vvbi entire site.,
Rolling:, slop
site generally less than 15% (a vertical, riseof. 10-feet -over, a
Wfeet).
vli) t4l; hdrizorital distanci6
IY�
'slopes :on site of more than 15% and less diari,30% (a vertical'rise-
presem
r . o f
104eet6v6ra ormontal distance bf.33 to 66-feet).-,
.Steep: ,,-grades of greater than 30% present on site (a vertical rise of 10-feet overa
borizontal distance of less than 33-feet).
(please descri!n):1.Y.'."�'..
Ald
6. Site contain-s-areas of Ycif-tound-st'ainding water. Approk. D�P�'
7.. Site c� ns aiia's 4 seis�nal itahiding'
VrZter.,, LJO Approx. Depth::
What ssa�909, q* iw
8. Site is in4he f "J!,
An -WO of a water ' course.
9. Site contains a-cteek or'an am xi4ij�jwaa_ flows across the grounds surface? Flows are year-
round? "'Flows are sea . sonal? /,/b (What time of year?
10. Site is pr'unarily-.*' f6rested.- ow shrubs mixed
urban landscaped (lawn,shr-ubs etc)
11. Obvious wetland is present on site -
City Staff Use Only
1. Site is Zoned?
2. 9CS mapped soil type(s)? —Min
3. Weiland inventory or C.A. map indicates , wetlandkresent on site? PC)
4;,. --,Critical ij�as inventory of C.A. map indicates Critical Area on site?
5. within designated earth subsidence landslide hazard area?
6. designated on the Environmentally Sensitive Areas Map? �j 0.
.DETiRMWATI0N.__..
:'�)WDY REQUIRED
1`__�AIVER
Revi�wed by--
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CritICk6[.-,`A;-re
'Me Critical
Areaf L"I =,Id& on
to' Y .4m..'subinitiito e ity will
this form is be filled I . , . — 00C �E.Tb C
any person review the d=WS4, make a precursory site,
preparing a Development pjil�t -P,
-a-deteirim'Ination of th6--
-Visit, �and*ft
Application for the City of Ed
iii6n& prior", subskq� u"e' nks,tepi" i necessary to complete a
en perm- icati6i'
to his/her submittal of a development' t it app]
Permit to the City.
Affigned-copy -of this fo
The purpose of the Cheddiit rrn�
2PPh=;SbQWd also submit a vicinity map
City staff to deAeiTfiifie�-W-hjffijj�
apy Ir PW,Plm iviotio-lots 0
C for inoi F -parcel,
potential Critical Aze�s -the
are or may be' With C6DUgb dctail that City staff can find
Present on the subject property'vni
e-
inforinati6n needed to complete the ect pa
adMon.
f
r
Checklist shouldbe easily available 01;�
11formation IteI
'Obsel'ValiOns; of the site',or Ajj� �' - '- , - f
avazi�biea Ian, t6
.11-181-1—P., . P09MPh*nI2P3, etc-) orstudies in,.,
City IWI (Critical Areas inventodes, mapi, .,�i ... �, i . , - ,�, - -, � , " - - " -
or sod surveys). to -assist
staff in i ng Their preliminary
4as�ment of. ffie siti:
An applicant, or hi:�� 114* ta*tive,
must fill out the checklist, sign and date it,
I have completed the- attache*d" Critical Area Checklist and attest that the answers
factual, to the best of my'knowledge (fill out the appropriatd column below).
provided are
Owner
I Applicant:
Applicant Representative:
kT.
Name
Nam
Street Address
Street Address
City, State, Zip
F hdhe City, State, ZIP-
Pho
A
Signature 77-�
te Signature
Pate .�.zs