Request for CE.pdfRD201q-087<D)
pt EDMo Citv of Edmonds
Al �-o Development Services Department
121 5`" Avenue North
> Edmonds, WA 98020
Phone: 425.771.0220 Fax: 425.771.0221
1,690 Email: codeenforcement@ci.edmonds.wa.us
Date Received:
For City Use Only:
File No: )nw/ant9
1.
2.
If you have distinctive handwriting you may choose to type this form.
Alleged Violator's Name/Phone: f1(e V V 1 'r
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Violation Address or Site Location: 20 5 i C__,� %
DETAILS OF REQUEST: (Please be accurate, complete and ppecific)
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The City of Edmonds investigates possible violations on a request basis only. Therefore, the name of
the person filing the request must be provided in order for the city to investigate.
Name (please print Phonel4z-1— ;72 '-09-3%
s r (Area Code)
Address: 0.5 Z� ~
(Street Address) (City) (State) (zip) (email address)
Pursuant to State Public Disclosure Law RCW 42.56.240(2), the complainant may indicate a request for
non -disclosure of their name and identity. If non -disclosure is desired, the bottom portion of this form
which indicates your identity as a complainant, will be redacted (blacked out) prior to public
disclosure.
If you do not want your identity disclosed, check the box and sign on the line provided. Thank you.
DO NOT DISCLOSE MY IDENTITY R
Signature: Date
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