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Critical Areas Checklist CA File No: �_ �Lz
Site Information (soils/ topography/ hydrology/ vegetation)
1. Site Address/ Location: -I_Z(00 % 9 A L,,<- W
2. Property Tax Account Number: 00 5W3 _000 e2,r-2,1-40
3. Approximate Site Size (acres or square feet): IN o,.cre,
4. Is this site currently.developed? J?'�yes; — no.
If yes; how is site developed? C, F- P,
5. Describe the general site topography. Check all that apply.
Flat less than 5-feet elevation change over entire site.
Rolling: slopes on site generally less than 15% �(a vertical rise of 10-feet over a horizontal
distance of 66-feet).
Hilly: slopes present on 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
distance of less than 33-feet). a vertical rise of 10-feet over a horizontal
Other (please describe):
6. Site contains areas of year-round standing water: NO Approx. Depth:
7. Site contains areas of seasonal standing water: NO Approx. Depth:
. I
What season(s) of the year?
8. Site is in the floodway 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?
A/O Flows are seasonal? — (What time of year?
10. Site is primarily: forested _ ; meadow ;shrubs mixed
urban landscaped (lawn, shrubs etc) V____
11. Obvious wetland is present on site: AID
For City Staff Use Only
1. Plan Check Number, if applicable?
2. Site is Zoned?
3. SCS map d soil type(s)? kMA c>d 9 L_),n
4. Critical Areas inventory or C.A. map indicates Critical Area on site?
5. Site within designated earth subsidence landslide hazard area?
Ar � .- . A r1__, ('7))/- C__'. J-1 -, - n
DETERMINATION
STUDY REQUIRED X WAIVER
Reviewed bv,.::�-- C), n�# (:�k — �P,
Critical Areas Checklist.doc/4.22.2003
OV ED&
City of Edmonds
Development Services Department
Planning Division
Phone: 425.771.0220
4"o C. 1 9 QJ Fax: 425.771.0221
The Critical Areas Checklist contained on this form is to
be filled out by any person preparing a Development
Permit Application for the City of Edmonds prior to
his/her submittal of the application to the City.
The purpose of the Checklist is to enable City staff to
determine whether anv notential Critical Areas are ,
Date Received:
City Receipt#: t;kq 5,3 ( —0
Critical Areas File #: 6-1— 12-0
Critical Areas Checklist Fee: $135.00
Date Mailed to Applicant:— -03
A property owner, or his/her authorized representative,
must fill out the checklist, sign and date it, and submit'it
to the City. The City will review the checklist, make a
precursory site visit, and make a determination of the
subsequent steps necessary to complete a development,
permit application. . I`
2
may be, present on the subject property. The information Please submit a vicinity map, along with the signed copy
needed to complete the Checklist should be easily of this form to assist 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
surveys). information (e.g. site plan, topography map, etc.) or
studies in conjunction with this Checklist to assistant staff
in completing their prelirminary assessment of the site.
The undersigned applicant, and his/her/its heirs, and assigns, in consideration on the processing of tl�e application 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 or
incomplete information fumished by the applicant, his/her/its agents or employees.
By my signature, I certify that the information and exhibits herewith'submitted are true and correct to the best of my
knowledge and that I am authorized to file this application on the behalf of the owner as listed below.
SIGNATURE OF APPLICANTIAGENT
DATE
Property Owner's Authorization
By my signature, I certify that I have authorized the above Applicant/Agent to apply for the subject land use application,
and grant my permission. for the pu�hcfficiaj� and the,;tg of th
�py of Edmonds to enter the subject property for the
purposes of inspection and posting/4tAdanVi thi�4p on. Zl
SIGNATURE OF OWNER
Owner/Applicant:
� Dcj- r k Q n & C- U1�4tLl\
Name
9 -2 `4 A
Street Address
EAM043, W P, w 0 lo
City I State Zip
Telephone: V4- 606 -90 W
Email address (optional):
DATE 15
Applicant Representative:
Name V
?0 ZO)c -77S52-,
Street Address
5-e LjA 9% 171
'City V State Zip
Telephone: Uo- 306-IDLO/
Email Address (optional):
Critical Areas Checklist.doc/4.22.2003