landuse application.pdfRECEHVC-D
City of Edmonds
MAR 14- 2012
Land Use Application IIEVELOPMENT SERVICES
COUNTER
D ARCHITECTURAL DESIGN REVIEW FOR OFFICIAL USE ONLY
C COMPREHENSIVE PLAN AMENDMENT 'R '�L
E CONDITIONAL USE PERMIT FILE 4 -1kYDOQZW1 ZONE F -I—", — -
F� HOME OCCUPATION DATE RECD By e"e
E, FORMAL SUBDIVISION
F- SHORT SUBDIVISION FEA, RECEIPT
F LOT LINE ADJUSTMENT HEARING DATE
E PLANNED RESIDENTIAL DEvFi,oPmFN"r
E OFFICIAL STREET MAP AMENDMENT HE XSTAFF El PB D ADB -1 CC
F STREET VACATION
E REZONE
E SHORELINE PERMIT
F VARIANCE / REASONABLE USE EXCEPTION
9 OTHER: —ItCe- C-emo\r6d
PROPERTY ADDRESS OR LOCATION 1%110
PROJECT NAME (IF APPLICABLE)
PROPERTY OWNER Cdr m Fe be ra, i PHON-3kC)- :Z J- 0 ill
o J3 I -B,,,1hyiokavii 04 E# qg2 Is
ADDRESS
E-MAIL FAX 4
TAXACCOUNT# C)0309'99000001CC SEC. TWP. RNG.
DESCRIPTION OF PROJECTOR PROPOSED USE (ATTACH COVER LETTER AS NECESSARY)
Seg_ r. rcA b, Wr
DESCRIBE HOW THF. PROJECT MEETS APPLICABLE CODES (ATTACH COVER LETTER AS NECESSARY)
See&AAchfzi 16iler
APPLICANT&c corj4 T. Fr 4r r` -&n PHONE# -3 &o — 7
ADDRESS -Po �ut, PIA nk -2 �q, F>
E-MAIL FAX 4
CONTACT PERSON/AGENT PHONE 4
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 applicatiomo4i the behalf ofthe owner as listed below.
SIGNA JURE OF APPLICANT/AGENT
DATE
Property Owner's Authorization
1, , 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
subject property for the purposes of inspection and posting attendant to this application.
SIGNATURE OF OWNER DATE
Questions? Call (425) 771-0220.
Revised on 9114170 B - Land Use Application. doc Page 1 of I