Glenbrook Application.pdfCity of Edmonds
Land Use Application
❑ ARCHITECTURAL DESIGN REVIEW
❑ COMPREHENSIVE PLAN AMENDMENT
❑ CONDITIONAL USE PERMIT
❑ HOME OCCUPATION
F1 FORMAL SUBDIVISION
Fl SHORT SU13DIVISTON
❑ LOT LINE ADJUSTMENT
❑ PLANNED RESIDENTIAL DEVELOPMENT
❑ OFFICIAL STREET MAP AMENDMENT
❑ STREET VACATION
❑ REZONE
FI SHORELINE PERMIT
❑ VARIANCE / REASONABLE USE EXCEPTION
❑ OTHER:
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FEE a s.r RECEIPT #
HEARING DATE
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ON CONTAINED
� WITHIN TH�%E APPLICATION IS A PUBLIC RECORD *
PROPERTY ADDRESS OR LOCATION. _ �� Tl O I- �& /
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PROJECT NAME (IF APPLICABLE)._ �reLl ,- P 1.170 ✓a
PROPERTY OWNER „m•mmm//i h+'t
ADDRESS �...........--_ /a �Si
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TAX ACCOUNT #
PHONE#
FAX #
SEC. TWP. RNG.
I.DL"st Rll jIoN OF, i"1'(OJ C -r OR PROPOSED USE (ATTACH COVER LEI T T T R AS Nl S I SSA" RY)
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DESCRIBE HOW THE PROJECT MEETS APPLICAM E CODES (ATTACH COVER LETTER AS NECESSARY),• • ____
APPLICANT /(BNIU VU N?QwI...-P✓LS,dc'*........PHONE#._......... ....
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E-MAIL E � _' �3Hf�L�t r L t t.. �� FAX 4
CONTACT PERSON/AGENT
ADDRESS
E-MAIL ffaC ?w a 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.
fly my signature„ I cter iT'"y Ihat the inforniati(m and cxhibi�trs herewith submitted tyre true and corr"i ttw the best of" my knowledge
hC ns hwtetl heticnv.
SItaNAtl"i,NlN1lfd�lAlr"N°t td ANrl1`/AIR,6 tllltlrt:^�Ni�rontrt��l�tS. �Cl�tw�t6ra rwna� t ..• ATE
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Property Owner's Authorization
I certify under the penalty of perjury under the laws of the State of
�Vashrngton that the following is a true and correct statement: 1 have authorized the above Applicant/Agent to apply for the
snrtapcct land use application, and grant my permission for the public officials and the staff of the City of Edmonds to enter the
RECEIc;I property for the purposes of inspection and posting attendant to this application.
MAR 1 7 201 SIGNATURE OF OWNER
Questions? Call (425) 771-0220.
DATE
B - Land Use Application Page I of]
,)LVGLOPMEN7 SERVICE j2erisedon8/22/12 PP