APPLICATION.pdfCity of Edmonds
Land Use Application
V ARCHITECTURAL DESIGN REVIEW
❑ COMPREHENSIVE PLAN AMENDMENT
❑ CONDITIONAL USE PERMIT
❑ HOME OCCUPATION
❑ FORMAL SUBDIVISION
❑ SHORT SUBDIVISION
❑ LOT LINE ADJUSTMENT
❑ PLANNED RESIDENTIAL DEVELOPMENT
❑ OFFICIAL STREET MAP AMENDMENT
❑ STREET VACATION
{ REZONE
p1 SHORELINE PERMIT
❑ VARIANCE / REASONABLE USE EXCEPTION
❑ OTHER'
FILE # w`' tiL ZONE
DATE ° `, s 07 REC'D BY
FEE RECEIPT #
HEARING DATE
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MCEWED
JUN VS, '° 17
DEVELOPMENT
. aP1,ENSa• Nffrf, TIL,j r AL J INFO MPaI 4TION CONTA N'JM^ED W1 THIN THE APP1 KA TION''IS A PUBLIC BECORzW I J N T
PROPERTY p IF APPLICABLE ` O MMNA MP ° s w a
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PROJECT NAME (
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PROPERTY OWNER � � Pllt,"YNL
ADDRESS J,5(0 �AiRO A ,A b 1,0
E-MAIL FAX #
TAX ACCOUNT # SEC. TWP. RNG.
DESCRIPTION OF PROJECT ORP O S p US ( TT CH COVER LETTER AS NECESSARY)__ ___........
DESCRIBE HOW THE PROJECT MEETS APPLICABLE CODES (ATTACH COVER LETTER AS NECESSARY)
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APPLICANT PHONE # „_._
ADDRESS
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E-MAIL ...... .. FAX # .
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CONTACT PERSyON/At3ENT PHONE #
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E-MAIL Sl ,IJAW \ 1• �tJ i � t I � ���h Wm FAX# .Q.0.
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, inaccurate or incomplete information
furnished by the applicant, his/her/its agents or employees.
By my signature, I certify that the inforniat'irun ' N rl c'.hib'm herewith submitted are true and correct to the best of my knowledge
and that I am authorized to file this applicatir a Italf of the ow � Ips �ala'twv.
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SIGNATURE OF AI N LicAN V AGI.'. NT ; DATE 6-01.17
Pro twrt O Authorization
Washington that atruettrl correct.. ..., certify under the penalty of perjury under the laws of the State of
at the following statement: I have authorized the above Applicant/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 Inulmsc oM nlspectaon nand pu°a�/ssiing attendant to this application. 11//
CTt:N A TT TR F nP OVJNFR °� ��9r �. � C.�r DATE b ). Y)do
Revised on 8/22/12 B - Land Use Application Page 1 of I