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De�.d6pm��i`,§'e'rvices Department, Y
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Plarinin Divigion',"
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Phone: 425.771.0220 Critic.alAre,ar;�C—h'ec,kl.*Ist�Fe6'
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Fax: 42�371.0221 t.
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The Critical Areas Checklist contained. on this. form is to 'A property -owner, ' 617'his/her authorized representative,
be filled out by any person preparing a Development must -fill'out the checklist, sign. and, date it, and,submit it
Permit Application -for the City of Edmonds poor to to the City. The City will review the checklist, make a
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his/her submittal of the application to the City precursory site visit, an
& make I a dete'rmination of the
The purpose of the Checklist is to enable, City staff to subseq ent. steps. necessary: to complete a development
determine whether any potential Critical Areas are permit application.
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may be, present on the subject property. The information Please submit a vicinit
y map, along with the signed copy
needed to completL- the Checklist should be easily of this form'io** a's�ist` City sta'ff 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, iri'co'rij6cti6n with'thi's Checklist to assistant staff
in �,Omplefing 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, 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, Jn ccurate or
incomplete information furnished'by the applicant, his/hei/its agents o . r employees.
By my signature, I cer* that the infbrqu�tion and exhibits herewith submitted are true and correct to the. best of my
knowledge and that I am authorized to fii�,, t1his appli If of thei owner as listed b low.
SIGNATURE OF APPLICANVAGEN DATE. 871,1,,,
Property Owner's Authorization
By my signature, I certify fttill'have authorized the above.Applic* afit/Agent-to;apply for the subject land use application,
and 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 posting attendant to this application.
SIGNATURE OF ER DATE— 16 Z_�
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Owner/Applicint:
V! ry, L4 V\
Naj e ti ..
Street Address
L 02-D
City State Zip_
Telephone; iotp - 57q z - H 3�
Email address (optional). -
Critical Areas Checklist.doc/3.19.2001
Street Address
-5ecJk�_ �-J�
City.' State Zip
Telephone: 2Q& Mi -JOW
Email Address (optional):