LandUseApplication.pdfCity of Edmonds"
Land Use Application
ARCHITECTURAL DESIGN REVIEW SMIZINIM
COMPREHENSIVE PLAN AMENDMENT
CONDITIONAL USE PERMIT FILE # V L®t S 00y2 ZONE
HOME OCCUPATION DATE ®J REC'D BY —
FORMAL SUBDIVISION
SHORT SUBDIVISION FEE 20 GG 2.. o ® RECEIPT #
LOT LINE ADJUSTMENT HEARING DATE
PLANNED RESIDENTIAL DEVELOPMENT
OFFICIAL STREET MAP AMENDMENT STAFF PB ADB CC
STREET VACATION
REZONE
SHORELINE PERMIT
VARIANCE / REASONABLE USE EXCEPTION
OTHER:
a PLEASE NOTE THAT ALL INFORMATION CONTAINED WITHIN THE APPLICATION ISA PUBLIC RECORD a
PROPERTY ADDRESS OR LOCATION
PROJECT NAME (IF APPLICABLE)
PROPERTY OWNER `'`} i S PHONE #
ADDRESS
E-MAIL FAx #
TAxACCOUNT # 0o15 -Q5 6-1 `0 Z5 -op SEC. TWP. RNG.
DESCRIPTION OF PROJECT OR PROPOSED USE (ATTACH COVER LETTER AS NECESSARY)
DESCRIBE HOW THE PROJECT MEETS APPLICABLE CODES (ATTACH COVER LETTER AS NECESSARY)
APPLICANT �� PHONE # Z
ADDRESS Zt (nom l - �1 iAA � t JET„ Ea t`A0LJV_>
E-MAILe {r�E tj Si.�G�tSI-t 0 FAX#
CONTACT PERSON/AGENT M tr'�� Y PHONE # AZ%i
ADDRESS '7-U00t" lu-1'4 �� trl��iT { l9it�7M�1-SCIS
j -MAH 1C 1�t @. ?tel Iy J 1�S5a((iS S < CfJt'"t 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 exhibi i tttisted
c true and correct to the best of my knowledge
and that I am authorized to file this application on; 15 o cr below. t
SIGNATURE OF APPLICANT/AGENT DATE
Property Owner's Authorization
I, 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
subjectro for the purposes of'in inspection and sting attendant to this application.
SIGNATURE OWNER ur P DATE 7 711„
tions? Call (425) 771-0220.
Revised on 8/22/12 B - Land Use Application Page I of I