20121102071131782.pdfO4 EQ', City of Edmonds
�d Development Services Department
121 5'h Avenue North
Edmonds, WA 98020
Phone: 425.771.0220 Fax: 425.771.0221
rnC' 1169° Email: codeenforcement@ci.edmonds.wa.us
Date Received:
For City Use Only:
File No:
1.
0
The City of Edmonds investigates possible violations on a request basis only. Therefore, the name of
the person filing the request must be provided in order for the city to investigate.
Name (please print): K e� � Phone:
(Area Code
Address: E[ C %(°�
(Street Address) (City) (State) (dip) (emaiE address)
Pursuant to State Public Disclosure Law RCW,42.56.240(2), the complainant may indicate a request for
non -disclosure of their name and identity. If non -disclosure is desired, the bottom portion of this form
which indicates your identity as a complainant, will be redacted (blacked out) prior to public
disclosure.
If you do not want your identity disclosed, check the box and sign on the line provided. Thank you.
IDENTITYIK
Signature: Date
L:TEMPIBUILDINGIFORMSILand Use Complaint Form.doc #46