PLN2021-0071_Water Availability Application_3.25.2022_9.04.48_AM_2761156or EVkfC,
WATER AVAILABILITY APPLICATION R E S U B
Complete and submit this form through www.MvBuildingPermit com' 3/25/2022
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CITY OF EDMONDS
DEVELOPMENT
SECTION A SERVICES DEPARTMENT
Applicant information
Contact/Applicant Name Randy Brockway
Phone Numbe 206 992-5051
Email randybrockway@yahoo.com
Address 11014 19th Ave SE, Ste. #8-315
City Everett State WA
Zip 98208
Property Information
Project Name Gustafson SP
Associated Permit NumberPLN2021-0071
Address 9009 192nd St SW
CityEdmonds State WA Zip 98026
Parcel No. 00434600002903
Does the property currently have water service? 9 Yes (City of Edmonds water) ❑ 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
iZ Preliminary Plat
❑ Building Permit
❑ Rezone or Other
Associated permit application number(s), if applicable: PLN2021-0071
SECTION B
Applicabilit3
V Applicant certifies that this project is a single-family residence, multi -family project of four units or
less with combo water/fire lines, 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 through www.MvBuildinEPermit.com.
APPLICANT SIGNA
APPLICANT PRINTED
TE: 3/ /
Form Updated 12/9/2021