Taub Application.pdfCity of Edmonds
Land Use Application
RECEIVI
ELOPMENT SERt110EF,
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❑ ARCHITECTURAL DESIGN REVIEW OFFICIAL, USE
❑ COMPREHENSIVE PLAN AMENDMENT
❑ CONDITIONAL USE PERMIT FILE # �¢[6606'1 ZONE `....
❑ DOME OCCUPATION DATE REC'D BY mw ........ _.,
❑ FORMAL SUBDIVISION
❑ SHORT SUBDIVISION FEE �RECEIPT #
LOT LINE ADJUSTMENT HEARING DATE
❑ PLANNED RESIDENTIAL DEVELOPMENT
11eS OFFICIAL STREET MAP AMENDMENT ❑ BE FAFF ❑ PB ❑ ADB ❑ CC
❑ STREET VACATION
❑ REZONE
❑ SHORELINE PERMIT
❑ VARIANCE ( REASONABLE USE EXCEPTION
❑ OTHER:
o PLEASE NOTE THAT ALL INFORMATION CONTAINED WITHIN THE APPLICATION IS A PUBLIC RECORD 'a
PROPERTY ADDRESS OR LOCATION
PROJECT NAME (IF APPLICABLE)
PROPERTY OWNER, ��,i tlr1h)� ili r ,w,7" u@\D $PHONE#,_..m.........
ADDRESS ------ _----- —
E-MAIL_._ _ FAX # ... ......
TAX ACCOUNT # i°.�t (a �" sEc.l-3� L TWP; RNG.�'
"4411 T117N OF PROJECTOR PROPOS D USE (ATI'At d I COVER LETTER AS NECESSARY)
N
DI t SCRIB HOW THE PROJECT MEETS APPLICABLE CODES COVER LF"I`TER AS NLCE SARY)' —
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WAPPLICANT.." Ik PHONE .
ADDRESS
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E-MAIL � ' } 4 - , +�` �� J FAx #
CONTACT PERSONIAGENT `>' t V"t - t 7 PHONE # __
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, 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 exhlh s Isere 11 uI" ft are true and correct to the best of my knowledge
I I a � � � I�e�d below. DATE
SIGNATURE OF APPLICand that I am authorized Io file this ANT(AGENT}lac�a#itap � t the lath If ofthe own I �
ue.
Property Owner's Authorization
I, _V i Yv A 111 \ 5 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 purpose, f inspecti and po: ' tg attendant to this application.
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SIGNATURE OF OWNER ` M — '' DATE L �' 7,
Questions? Call (425) 771-0220.
Revised on 8122112 B - Land Use Application. doc Page I of]
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