Land Use Application.pdfCity of Edmonds (RECEIVED
Land Use Application OCT OB 2019
IlC\/CI And •ra.T ..�.� .. _ _ _
ARCHITECTURAL DESIGN REVIEW
COMPREHENSIVE PLAN AMENDMENT
CONDITIONAL USE PERMIT
HOME OCCUPATION
FORMAL SUBDIVISION
SHORT SUBDIVISION
LOT LINE ADJUSTMENT
PLANNED RESIDENTIAL DEVELOPMENT
0FFlC11 A L STR-"7T MAP A.;-- N EN T
STREET VACATION
REZONE
SHORELINE PERMIT
VARIANCE / REASONABLE USE EXCEPTION
OTHER:
FILE # CI.31MIOU,Z1 ZONE
DATE 10 " _ REC'D BY
FEE RECEIPT #
HEARING DA 1.
HE GAFF — PB — ADB — CC
• PL EASE NOTE rH AT ALL Wl /NFORMAT/ON CONTAINED W'/TH/cI N TfLE.APPPLfc.4 rf�ON fS 4 PUBLIC RECORD*� �/�
PROPERTY" ADDRESS OR LOCATION C) U 16 1 l l.1LG` J .� I► `, [;— t �4� S r V \�Ut12
PROJECT NAME (IF APPLICABLE)
PROPERTY OWNER
ADDRESS
PT40NE #
WnK� E1
M
E-MAII._ _ FAX # �+
TAX ACCOUNT # OO'� S�{ (pOdIDDD % 00 sEr. TwP. 'L RN(i. T_
DPSCRIPTION OF PROJECTOR PROPOSED Usti (ATTACH COVER Li-I-Tuk AS NECESSARY).._aIN11 51 fsbL
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APPLICANT
ADDRESS
E-MAIL
FAX
CONTACT PERSON/AGENT r ` (419 y I"t* 1451 PHONE #
ADDRESS
E-MAIL
FAX # 41,S ` 4 u 0— Ke:13
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 li'o 1 any and all damages, including reasonable attorney's
fees, arising from any action or infraction based in whole or part upo false, misleading, inaccurate or incomplete information
furnished by the applicant, his?herlits agents or employeekhcr
By mm y signature, T certify that the information and exhimitred are true and correct to the best of my knowledge
and thatI amauthorized to file thisapplica1, nontheber as listed below. i q
SIGNATURE OF APPLICANT/AGENT DATE O
Proper OLwner's rjuthorizatioM �� � ►J
I, _ dgi4� z&w , 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 d grant my permission for the public officials and the staff of the City of Edmonds to enter the
subject property for the pur os ; of ins/ectijon and pVting iWendent to this application.
DATE /j ;-� - ! /
Questions'? Call (425) 771-0220.
Revised on 8/2' 1' B - Land Use Appllcaltan Page I a% I