PLN20120007 Upper Dayton LU Application.pdfCity of Edmonds
Land Use Application
2ARCHITECTURAL. ESIGN REVIEW FOR OFFICIAL USE ONLY
-- 1 COMPREHENSIVE PLAN AMENDMENT �77
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CONDITIONAL USE PERMIT
HOME OCCUPATION DATE RE-C'D BY
I E . FORMAL. SUBDIVISION FEE EE RECEIPT 4
SHORT SUBDIVISION
LOT LINE ADJUSTMENT HEARING DATE
PLANNED RESIDENTIAL Dr-vEL0PTvIFNT
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0 OFFICIAL STREET MAP AMENDMENT HE STAFF PB ADB E] CC
STREET VACATION
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SHORELINE PERMIT
VARIANCE / REASONABLE USE EXCEPTION
OTHER:
PROPERTY ADDRESS OR LOCATION ;40 2,01- P--�kC-L
PROJECT NAME (IF APPLICABLE).
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PROPERTY OWNER PHONE#
ADDRESS
E-MAIL FAX #-
TAXACCOUNT# SEC. — TwP. RN, G.
DESCRIPTION OF PROJECT OR PROPOSED UsE (ATTACH COVER LETTER AS NECESSARY)
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DESCRIBE HOW THE PROJECT MEETS APPLICABLE CODES (ATTACH COVER LETTER AS NECESSARY)
APPLICANT F—� Oka klt� TOWVI A550(,( OkS U-(- PHONE 4 425 -
ADDRESS ?C1 ftlr' .5 00-f5 O?W�U90 LA-c Wr�- C10c,
CO E-MAIL VLd X n�I� X 0-t2 5 Tfq FAX 4 1425 - 45+, L7?V5-
CONTACT PERSON/AGENT 7`a C7L�4 RZEJ A0 PHONE#
ADDRESS
E-MAIL r2anxz,- 0, fhr)afz� cnz 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 application on the behalf of the owner as listed below.
SIGNATURE oFAPPLICANT/AGENT �Jakq kA�O&Iqqa— DATE
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Property Owner's Authorization
1, ae 6)A vmol-� certify under the penalty of perjury under the laws of the State of
Washington t ait 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 vlekt4 K0041bff - DATE Z--
0
Questions? Call (425) 771-0220.
Revised on 9174110 B -Land Gse.4pplicafion Page 1 of I