Miller Application.pdfCity of Edmonds
Land Use Application
❑ ARCHITECTURAL. DESIGN REVIEW
❑ COMPREHENSIVE PLAN AMENDMENT
❑ CONDITIONAL USE PERMIT
❑ HOME OCCUPATION
❑ FORMAL SUBDIVISION
❑ SHORT SUBDIVISION
,, LOT LINE ADJUSTMENT
❑ PLANNED RESIDENTIAL DEVELOPMENT
❑ OFFICIAL STREET MAP AMENDMENT
❑ STREET VACATION
❑ REZONE
❑ SHORELINE PERMIT
❑ VARIANCE / REASONABLE USE EXCEPTION
❑ OTHER:
JUL `5 2316
UUVELUNNIENIl SERVICES
FILE # 1+�� �W, REC,ONE N
DATE -II-� b DBY e�
FEE K V RECEIPT #
HEARING DATE
❑ HE STAFF ❑ PB ❑ ADB ❑ CC
• PLEASE NOTE THAT ALL INFORMATION CONTAINED WITHIN THE APPLICATION IS A PUBLIC RECORD •
O
PROPERTY ADDRESS OR LOCATION / %/3 d / 6$ r /,'109 Lam/.
PROJECT NAME (IF APPLICABLE)
PROPERTY OWNER G r/ C 1-0�pl; //e r PHONE #
ADDRESS 1,F3 00 jT R �1-04/AVa - s,✓
E-MAIL P_ P;C PpVt ller // 6) yj~q'I/ • Cy--% FAX#
TAX ACCOUNT # 0091 S/d D O 0 0 / SO S/ SEC. / &-_ T WP. Z % RNG.
DESCRIPTION OF PRoirtcr OR PROPOSED USE (ATTACH COVERLET-17 R AS NECESSAR
THE PROJECT MELTS APPLICABLE CODES (ATTACH COVER LETTER AS
APPLICANT pgrr-h /tiNv/ /� PHONE# /L5'r70
ADDRESS 1°(� B�Zx /3 6/q i >> Cyr�k� ''Y✓�' 9000—
E-MAIL b4rrc,111 ® 645 NrYCY-4 - "P� / FAX #
CONTACT PERSON/AGENT b1rr4=e X ayl-e PI IONF #
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, indemnity, 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
famished 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 APPLICANVAGENT
DATE
Property Owner's Author tion
AAkclle-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 pu oscs of inspecttipn and posting attendant to this application. J
SIGNATURE OF OWNER �_� J� J —DATE • o
Questions? Call (425) 771-0220.
Revised on 8122/I2 B - Land Use Application Page I of]