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23703 80TH CT W
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TAX ACCOUNT/PARCEL NUMBER:
BUILDING PERMIT (NEW STRUCTURE):
COVENANTS (RECORDED) FOR:
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CRITICAL AREAS:
DISCRETIONARY PERMIT #'S:
DRAINAGE PLAN DATED:
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED FOR:
PERM[ITS (OTHER):
PLANNING DATA CHECKLIST DATED:
SCALED PLOT PLAN DATED:
. DETERMINATION: E] Conditional Waiver [] Study RequireKWaiver
SEWER LID FEE $:
SHORT PLAT FILE: LOT:
SIDE SEWER AS BUILT DATED:
SIDE SEWER PERMIT(S) #:
SOILS REPORT DATED:
STREET USE / ENCROACHMENT PERNHT #:
WATER METER TAP CARD DATED:
OTHER:
LID
BLOCK:
L:\TEMP\Dsrs\Fonns\StTeet File Checklist.doc
0
City of Edmonds
Development Services Department
Planning Division
Phone: '425'771.0220
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 any potential Critical Areas are, or
may be, present on the subject property. The information
needed to complete the Checklist should be easily
available from observations of the site or data available at
City Hall (Critical areas inventories, maps, or soil
surveys).
Date Received:-.-',51 f V 10-'!2
City Receipt#:_ I '�H (a'�) 0
Critical Areas File #: :-.? C,,0'3--W2-0
Critical Areas Checklist Fee: $45.00
Date Mailed to Applicant:
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.
Please submit a vicinity map, along with the signed copy
of this form to assist City staff in finding and locating the
specific piece of property described on this form. in
addition, the applicant shall include other pertinent
information (e.g. site plan, topography map, etc.) or
studies in conjunction with this Checklist to assistant staff
in completing their preliminary assessment of the site.
The undersigned applicant, and his/her/its heirs, and assigns, in consideration on the processing of the application agrees
to release, inderrinify, 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 furnished 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 ffii�llethis p ic �ie behal e owner as listed below.
4 7 DATE
SIGNATURE oF APPLicANT/AG
Property Owner's Author' ati�o�
10
By my signature, I cer* I Jia0e authorized the above Applicant/Agent to apply for the subject land use application,
and grant my permission for e public officials and the staff of the City of Edmonds to enter the subject property for the
purposes of inspection and posting attendant to this application.
SIGNATURE OF OWNER DATE
PLEASE PRINT CLEARLY
Owner/Appflcant:
"w rAP040 V
14ame
Street Address
4�6wOW5
city State zip
Telephone: (!�'?67
Email address (optional):
AppHcant Representadve:
i �, 6-5:
Name
1-701 Hc;e,-,,tir haar
Street Address
42/4
city State zip
Telephone: qZ!� - 7-572- -Z530,6
Email Address (optional): oht-R Okp-bl -wole-2>19-
Critical Areas Checklist.doet3.192001
0 0
-V. JJD7
City of Edmonds
Development Services Department
Planning Division
Phone: '425'771.0220
Fax: 425.771.0221
Ile 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 any potential Critical Areas are, or
may be, present on the subject property. The information
needed to complete the Checklist should be easily
available from observations of the site or data available at
City Hall (Critical areas inventories, maps, or soil
surveys).
Date Received: 0�2
City Receipt#: 1'�o ---5 0
Critical Areas File #: 200 _3 - CX) 2-
Critical Areas Checklist Fe�, �45.00
Date Mailed to Applicant:
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.
Please submit a vicinity map, along with the.signed copy
of this form to assist City staff in finding and locating the
specific piece of property described on this form. In
addition, the applicant shall include other pertinent
information (e.g. site plan, topography map, etc.) or
studies in conjunction with this Checklist to assistant staff
in completing their preliminary assessment of the site.
The undersigned applicant, and his/her/its heirs, and assigns, in consideration on the processing of the application agrees
to release, inderrinify, 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 cer* that the information and exhibits herewith submitted are true and correct to the best of my
knowledge and that I am authorized to file t is plicabo e owner as listed below.
SIGNATURE OF APPLicANT/AG DATE
r
Property Owner's Author* atio
By my *ignature, I cer* I e authorized the above Applicant/Agent to apply for the subject land use application,
s
and grant my pernmnission for e public officials and the staff of the City of Edmonds to enter the subject property for the
purposes of inspection and posting attendant to this application.
SIGNATURE OF OWNER
PLEASE PRINT -CLEARLY,
Owner/AppUcant:
"OW
Name
Street Address
16;6w,14�5 Y(;A fez: 6
city State zip
Telephone: t-l' �" !�Vo�;3
Email address (optional):
DATE
AppHcant Representative:
Name
-77, / Alc;cyl 7T- Alar
Street Address
qT— 42/a.
city State zip
Telephone: 1Y 7-572-
Email Address (optional): ).oh1,P okp-bl
Critical Areas Checklist.doc/3.192001