LandUseApplication.pdfCity of Edmonds
Land Use Application
ARCHITECTURAL DESIGN REVIEW
❑ COMPREHENSIVE PLAN AMENDMENT
❑ CONDITIONAL USE PERMIT FILE # X A Nl a
❑ HOME OCCUPATION,
DATE r RECD BY W
❑ FORMAL SUBDIVISION
❑ SHORT SUBDIVISION FEE RECEIPT #__
❑ LOT LINE ADJUSTMENT HEARING DATE
❑ PLANNED RESIDENTIAL DEVELOPMENT
❑ OFFICIAL STREET MAP AMENDMENT ❑ HE ❑ STAFF ❑ PB ADB ❑ CC
❑ STREET VACATION
❑ REZONE
❑ SHORELINE PERMIT
❑ VARIANCE / REASONABLE USE EXCEPTION
❑ OTHER:
• PLEASE NOTE THAT ALL INFORMA+A+TION CONTAINED WITHIN THE APPLICATION ISCA PUBLIC RECORD 0
PROPERTY ADDRESS OR LOCATION
PROJECT NAME (IF APPLICABLE),
PROPERTYOWNER L.1 (Z5V �1q►M.\�I PHONE# 4z5'ZLO'SSOZ
ADDRESS
Aia7<0 FAX# �-7
TAX ACCOUNT # On 41.Ip '3 3 U � G 8 0 SEC. TWP. RNG.
AS N
Pit Rcli 1 Aye" I'I> t ( i �" - R a")
Zx'sc,lup,1 0 OF PR�� 1SED l.JSF (Af i A4�'I"1 COVER N
HOW '1" Il: PROJECT APPLICABLE"CODES (A r;II COVJ" -1 Ix— T[ AS Nl 1,PS'SARY)
DESCRIBE
0A1 L
tZft
APPLICANT LPHONE#, S
ADDRESS
E-MAIL FAX # yZ5 ^% Li 1
CONTACT PERSON/AGENT SAL PHONE # y2J -2-10 SS6 Z -
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 exl '4'ails ltea`ew't1a submitted are true and correct to the best of my knowledge
and that I am authorized to file this applic�t' the elratl "art'tNr o eras listed below.
SIGNATURE OF APPLICANT/AGENT DATE 16
P'roprertOwner's Authorization
certify under the penalty of penury under the laws of the State of
Washington Oat the following is a true and c 'cut ststicp'wwe'nt; I have authorized the above Applicant/Agent to apply for the
subject land use application, and I renis ion for th ublic officials and the staff of the City of Edmonds to enter the
subject property for the purpo s oN mspe I n and sting, al c dant to this application.
SIGNATURE OF ()WNP,'R DATE
---........r
Questions? Call (425) 771-0220,
Revised on 8122/12 B - Land Use Application Page I of l