Keros Application.pdfCity of Edmonds
Land Use Application
❑ ARCHITECTURAL DESIGN REVIEW FOR OFFICIAL USE ONLY
❑ COMPREHENSIVE PLAN AMENDMENT
❑ CONDITIONAL USE PERMIT FILE # FL NA015'000I ZONE GG Z
❑ HOME OCCUPATION DATE REC'D BY Ten
❑ FORMAL SUBDIVISION _
❑ SHORT SUBDIVISION FEE _ �_SG RECEIPT #
❑ LOT LINE ADJUSTMENT HEARING DATE
❑ PLANNED RESIDENTIAL DEVELOPMENT r
❑ OFFICIAL STREET MAP AMENDMENT ❑ HE aSTAFF ❑ PB ❑ ADB ❑ CC
❑ STREET VACATION
❑ REZONE
❑ SHORELINE PERMIT
❑ VARIANCE / REASONABLE USSEE�ExCE�P-TION A
X OTHER: LANV,5Ca E MOD) r" (CArW f
• PLEASE NOTE THAT ALL INFORMATION CONTAINED WITHIN THE APPLICATION IS A PUBLIC RECORD •
PROPERTY ADDRESS OR LOCATION 9-Z3.2 4 Wunl qq C DM40 ND5
PROJECT NAME (IF APPLICABLE) <--i F14n,.J T l7 e•y
PROPERTY OWNER Y [C • IL _ PHONE # 4/ Z--5 7,:� A 129—
ADDRESS , . b. BQK Siq 3 - . S cA-77 L , IAA . �'81z I
E-MAIL 5C 3Qr- t/o'&do . 0-6 FAx #
TAX ACCOUNT # Z %Q ,Z 'Q�� 3�� jQQ SEC. Z? TWP. 2 7 RNG.
DESCRIPTION OF PROJECT OR PROPOSED USE (ATTACH COVER LETTER AS NECESSARY)
DESCRIBE HOW THE PROJECT MEETS APPLICABLE CODES (ATTACH COVER LETTER AS NECESSARY)
LANWCAPE :F A&I �M(XiZEMELIM
Z01. [3. a[6(A-32H lam) zd, i3. 61-5
APPLICANT STCmm C . GKAV PHONE # 207 , . 953 .. 16 ICS
6 ADDRESS 316 ,Z�Jr �— � • $. %�I - 0jM0 [0S , WA. 95*2-ic/,
E-MAIL QQ� a o, rr1 FAX #
CONTACT PERSON/AGENT UTEy -N d • C-(AV PHONE #
ADDRESS
E-MAIL G �ci �-a V� \%Q . C� h� FAx #
o ,
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 and exhibits herewith submitted are true and correct to the best of my knowledge
and that I am authorized to file this application the behalf of th owner as listed below.
SIGNATURE OF APPLICANT/AGENT - DATE
Pro erty Ow ' iza ion
I, certify under the penalty of perjury under the laws of the State of
Washington that th Ilowing is e and correct statement: I have authorized the above Applicant/Agent to apply for the
subject land use application, and grant myVermission 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 OWNER DATE
Questions? Call (425) 771-0220.
Revised on 8122112 B - Land Use Application. doe Page I of I