APPLICATION.pdfCity of Edmonds
Land Use Application
ARCHITECTURAL DESIGN REVIEW
❑ COMPREHENSIVE PLAN AMENDMENT
❑ CONDITIONAL USE PERMIT FILE # 9LN)L0t-*Q ZONE
❑ HOME OCCUPATION DATE REC'D BY�,
❑ FORMAL SUBDIVISION
❑ SHORT SUBDIVISION FEE, it k 5%5.o RECEIPT#
LOT LINE ADJUSTMENT HEARING DATE
❑ PLANNED RESIDENTIAL DEVELOPMENT
❑ OFFICIAL STREET MAP AMENDMENT 7 HE )QSTAFF L PB D ADB E CC
❑ STREET VACATION
❑ REZONE
❑ SHORELINE PERMIT
❑ VARIANCE / REASONABLE USE EXCEPTION
❑ OTHER:
o PLEASE NOTE THAT ALL INFORAIATION CONTAINED WITHEV THE APPLICATION ISA PUBLIC RECORD
PROPERTY ADDRESS OR LOCATION
PROJECT NAME (IF APPLICABLE) Y.QI 3 (---
I S iJ1AC C2A
r-Our6 917
PROPERTY OWNER J ) „.,P 12CI MAI C2,PHONE # AZ -5 I 1 : 5
ADDRESS
E-MAIL � FAX #
TAX ACCOUNT # _ _ _ SEC. TWP. RNG.
DESCRIPTION OF PROJECT OR PROPOSED USE (ATTACH COVER LETTER AS NECESSARY)
DESCRIBE OW iTHE � CT MEETS API 'I,jCAI°%C'.S CODES ATTACH COVER LETTER AS EfF(Eti;SARY')
APPLICANT PDO h 1 K-45 C—AAWI PHONE # .4 ° L-
ADDRESS- 1
E-MAIL%�� j���Q j/1 j1,,. FAX #
CONTACT PERSON/AGENT thsO 1,1G LCL PHONE #'4-V,-
ADDRESS
E-MAIL I ......_. FAX
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 information a exh'bits b it pd are true and correct to the best of my knowledge
and that I am authorized to file this applica i o tlo hs below.
r
SIGNATURE OF APPLICANT/AGENT %„ DATE
Property Owner's Authorization
I 1 .�f-� M'I , certify under the penalty of perjury under the laws of the State of
Washington that the following is a true and correct 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 purposes o'if�h,'ns ecdon and pc, ing atteatd° , t to this application.
SIGNATURE OF OWNER • Z'�' '
Questions Call (425)'771-0220.
Revised on 8122112 B - Land Use Application Page I of]