PLN2021-0071_Sewer Availability Application_3.25.2022_9.04.48_AM_2761157of EDAIC,
SEWER AVAILABILITY APPLICATION R E S U B
Complete and submit this form through www.MyBuildingPermit com. 3/25/2022
#C 189 CITY OF EDMONDS
DEVELOPMENT
SERVICES DEPARTMENT
SECTION A
Applicant Information
Contact/Applicant Name Randy Brockway
Phone Number (206) 992-5051
Email randybrockway@yahoo.com
Address 11014 19th Ave SE, Ste. #8-315
City Everett State WA Zip 98208
Property•
Project Name Gustafson SIP
Associated Permit Number PLN2021-0071
Address 9009 192nd St SW
City Edmonds State WA Zip 98026
Parcel No. 00434600002903
Does the property currently have sewer service? 10 Yes (City of Edmonds sewer) ❑ No
Proposed Development
Describe project (number of buildings, number of units, number of stories per building):
The proposal is to split the existing 0.54 acre lot into two lots and to construct 1 single family home with associated utilities.
The existing home is to remain, but outbuildings and pavement located to the west will be removed.
In what phase is the project?
❑ Design Review
V Preliminary Plat
❑ Building Permit
❑ Rezone or Other
Associated permit application number(s), if applicable: PLN2021-0071
i
Applicability
KJ Applicant certifies that this project is a single-family residence, multi -family project of four units or
less, or short plat subdivision (four single-family lots or less), in which case completion of a full utility
availability study shall not be required. Please sign below and submit this form through
www.MyBuildingPermit.com.
❑ For all other permit types, a utility availability study is required and associated fees will be due. Please
submit the complete application thrquM www.NIYBuildinj4Permit.com.
APPLICANT SIGNA
APPLICANT PRINTED
DATE: .t / iZ 2
Form Updated 12/9/2021