Land Use Application.pdfCity of Edmonds
Land Use Application
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0 PLEASEN'OTE IIIA T ALL LWVRAM TWA' COTVIAhVED TVIT11VV THE APPLICATION LSA PUBLIC RECORD o
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PROPERT), A DDRESS OR LOCATION
PRairct NAME, (IF APPIACABI,E)1�2
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DESCRIBE HOWTHE PROJECI MFf- I'S 1IPIA''U L'S (ATTACH COVER ITTP -L& AS NS&SARYL
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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 ba ed in whole or part Upon False, misleading, inaccurate or incomplete information
furnished by the applicant, his/her/its agents 6remployees.
By my signature, I certify that the inforinati( and I t I submitted are true and correct to the best of my knowledge
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and that I am au to file this applicam olItfill I- he listed t I
SIGNATURE OFT APPFICAN'L �=
DA Ft
Property Owner's Authorization
1, --- 1, . certify under the penalty of perjury under the laws of f'
the State o
Washington th, I, the following is a true and correct statement: I have authorized the above Applicant/Agent to apply for the
subject land LISC application, and grant my permission for the public officials and the staff of the City of Edmonds to enter the
suh.ject property for the PUrposes ofinspectron and attend JAI this application.
SIGNA r FLIM, OF OWNER DA "EF E iz)
Questions'.' Call (425) 771-0220.
Revised on 8 22 12 B - Land (Ac Application I'Cjg(! 1 of I