LandUseApplication.pdfCity of Edmonds
Land Use Application
❑ ARCHITECTURAL DESIGN REVIEW
❑ COMPREHENSIVE PLAN AMENDMENT t �f ►r 1
❑ CONDITIONAL USE PERMIT FILE # u`�'�� LONr �1`'r� 1 •
❑ HOME OCCUPATION DATE 1-4 REC'D BY �5
❑ FORMAL SUBDIVISION hQj� RECEIPT #
[I SHORT SUBDIVISION FEE
❑ LOT LINE ADJUSTMENT HEARING DATE
❑ PLANNED RESIDENTIAL DEVELOPMENT
❑ OFFICIAL STREET MAP AMENDMENT ❑ HE ❑STAFF ❑ PB ❑ ADB ❑ CC
❑ STREET VACATION
❑ REZONE
❑ SHORELINE PERMIT
❑ VARIAN r: / Rr:A 0�-NABllLE US XC-:PTION
( OTHER:
\ • PLEASE NOTE THAT ALL INFORMATION CO}TAINED WITHIN THE AIPPLICATION S A PUBLIC RECORD •
PROPERTY ADDRESS OR LOCATION 7 L)/ 1 � IAIwL'���l, l�Yt (Z�,1 �L,
PROJECT NAME (IF APPLICABLE)
n� y V I tfd IAA' /
PROPERTYOWNER o'e: / " ' /4 I 1 t PHONE #
ADDRESS _ _'FL"1D, / P! A V- sue `d+-i iL'D'i� t ,s I
E-MAIL � F i�i ! if r 5 1 YA\CO ° Com FAX#_�f!`
TAX ACCOUNT # SEC. TWP. RNG.
DESCRIPTION OF PROJE 1.UR PROPOSED USE (ATTAC11,COVER LFI- °R AS N rCESSARY)
Ern or- 3 C(4- 2vs lZb&ke s ni VVIt o 1►
i J�; , r i W* sTv
DESCRIBE HOW THE PROJECT MEETS APPLICABLE CODES (ATTACH COVER LETTER AS NECESSARY)
APPLICANT L i NM►K. L!enikt" PHONE#
ADDRESS ON A�']
E-MAIL �LLiL r l ia�,�.t� o < � a -Ak-6 a .0 ,' ,-r, FAX # A
CONTACT PERSON/AGE NTPHONE #
ADDRESS 0)6' /�7H v�A ✓� 492V
E-MAIL t� /1 A.TN �tA/ rN (A�YIG�sf per! FAx#--I&i 41
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 barmless 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 informatn and ex ' its her ith sub are true and correct to the best of my knowledge
and that I am authorized to file this application o b al o r listed below.
SIGNATURE OF APPLICANT/AGENT DATE
Pro Own is Authori, atlo
I, certify under the penalty of perjury under the laws of the State of
Was mgton that the following is a uc and corn t statement: I h. authorized the above Applicant/Agent to apply for the
subject land use application, and g y rmi no f bli ffi Is and the staff of the City of Edmonds to enter the
subject property for the purpos fin ccC lication. �% ^
SIGNATU E OF OWNER DATE ✓ r `� (vXr'
�� Questions? all (425) 7 - 220.
Revised on 8122112 B - Land Use Application rage i of r