Landuse Application.pdf❑ ARCHITECTURAL DESIGN REVIEW • ° • Y
❑ COMPREHENSIVE PLAN AMENDMENT FILE #
❑ CONDITIONAL USE PERMIT) f� (`A',� Z ZONE wis i„1”
_I HOME OCCUPATION
DATE N63� �,,�•. �� REC'DBY�
CI FORMAL SUBDIVISION
❑ SHORT SUBDIVISION FEE RECEIPT #
❑ LOT LINE ADJUSTMENT HEARING DATE
❑ PLANNED RESIDENTIAL DEVELOPMENT 1IE 7 STAFF ❑ PB ❑ ADB ❑ CC
❑ OFFICIAL, STREET MAP AMENDMENT
❑ STREET VACATION
❑ REZONE
0 SHORELINE PERMIT
VARIANCE / REASONABLE USE EXCEPTION
❑ OTHER:
PROPERTY ADDRESS OR LOCATION ION rhe' 4( 5r 1 -2 7,1 O✓ G '; 7 l �/ ,." rr;7 ✓
PROJECT NAME (IF APPLICABLE)
PROPERTY OWNER oC �,, J L r rs'- ✓ PHONE # ✓"...�^" ,p J
ADDRESS ° i > 1 1^°; f. /' %�1 aC ✓',/,
E-MAIL Z7 .S' r e x . J P r✓ , ,., :;µT FAX # /
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TAX ACCOUNT #�1 SEC.TwP. RNG. '
DESCRIPTION OF PROJECT OR PROPOSED USE (ATTACH COVER LETTER AS NECESSARY)
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DESCRIBE HOW THE PROJECT MEETS APPLICABLE CODES (ATTACFI COVER LETTER AS NECESSARY)
APPLICANT PHONE #
ADDRESS
E-MAIL FAX #
CONTACT PERSON/AGENT PIIONE #
ADDRESS
E-MAIL 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 as listed below.
SIGNATURE OF APPLICANT/AGENT DATE r z"� r'o r '' ✓
Property Owner's Authorization
I, /., pry x} j C 5i4 :r , 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, and grant my permission for the public officials and the staff of the City of Edmonds to enter the
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subject property ort e purposes o inspection an posting attendant to this application.
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SIGNATURE OF OWNER. DATE
Questions? Call (425) 771-0220.
Revised on 9/14/10 B - Land Use Application. doe Page I of]