Ketchum Application.pdf11
11
11
11
N.
City of Edmonds JUKl 2 2016 r
Land Use Application DEVELOPMENT SERVICES
COUNTER
ARCHITECTURAL DESIGN REVIEW
COMPREHENSIVE PLAN AMENDMENT
CONDITIONAL USE PERMIT
HOME OCCUPATION
FORMAT.. SUBDIVISION
SHORT SUBDIVISION
LOT LINE ADJUSTMENT
PLANNED RESIDENTIAL DEVELOPMENT
OFFICIAL STREET MAP AMENDMENT
STREET VACATION
REZONE
SHORELINE PERMIT
VARIANCE / REASONABLE USE EXCEPTION
O'171ER: - A A.
• PLEASE NOTE THAT ALL INFORhIA
PROPERTY ADDRESS OR LOCATION
PROJECT NAME (IF APPLICABLE)
FILE #PLO 9A j ZONE
DATE REC'D BY c
FEE RECEIPT #
HEARING DATE
❑ HE N$TAFF ❑ PB ❑ ADB ❑ CC
RITHIN TUE APPLICAT/ON IS A PUBLIC RECORD •
TAX ACCOUNT # / l o 4 77 5Ot/(iC/ 2 /2Jf::� SEC. TWP. RNG.
t
DESCRIPTION OF PROJECT OR PROPOSED USE (ATTACH COVER LETTER AS NECESSARY
APPLICANT
ADDRESS
E-MAIL
CONTACT PERSON/AGENT
ADDRESS
E-MAIL
PHONE #
FAX #
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 and exhibits herewith submitted are true and correct to the best of my knowledge
and that I am authorized to file this application on the behalf of the owner w listed below.
SIGNATURE OF APPLICANT/AGENT
Property Owner's Authorization
DATE
1, , certify under the penalty of perjury under the laws of the State of
Washington that the following is a true and correct st mcnt: 1 have authorized the above Applicant/Agent to apply for the
subject land use application, a grant nis.•' n public officials and the staff of the City of Edmonds to enter the
subject property for the purpo s o pee ' n 9. ng attendant to this application.
SIGNATURE OF OWNS % DATE ,
Questions? Call (425) 771-0220.
DEVELONVIEMT SERVICES
CGUNTER
ACCESSORY DWELLING UNIT AFFIDAVIT
On ni'y oath, I certify that I reside at % P7 z -1-72AIP A45 4dmonds, Washington, in
the primary or accessory dwelling unit for more than six months of every year.
Assessor's Parcel Number: COL115ao00 2-20D
STATE OF WASHINGTON )
COUNTY OF SNOHOMISH )
Subscribed and sworn to befo tie this 2,2? day of Jy N Zy
N Public in and for ie State of Washington
Residing at CD"NPS'Tf0\)V-0T--
Notary Public9tgte of Washington
SHELRY HOPE ARNOLD
My COMMISSION EXPIRES
Jan Ia 21.2020
ADUAFFIDAVIT.DOC