BLD2021-0474+Land Use Application+4.4.2021_5.47.07_PM+2126406City of Edmonds
Land Use Application
❑ ARCHITECTURAL DESIGN REVIEW
0 COMPREHENSIVE PLAN AMENDMENT FILE # ZONE
❑ CONDITIONAL USE PERMIT
❑ HOMEOCCUPATION DATE REC' D BY
❑ FORMAL SUBDIVISION
❑ SHORT SUBDIVISION FEE RECEIPT#
❑ LOT LINE ADJUSTMENT HEARING DATE
❑ PLANNED RESIDENTIAL DEVELOPMENT
❑ OFFICIAL STREET MAP AMENDMENT 0 HE ❑ STAFF ❑ PB ❑ ADB ❑ CC
❑ STREET VACATION
❑ REZONE
❑ SHORELINE PERMrr
K VARIANCE /REASONABLE USE EXCEPTION
❑ OTHER:
• PLEASE NOTE THAT ALL INFORMATION CONTAINED R'ITMN THE APPLICATION IS PUBLIC RECORD •
PROPERTY ADDRESS OR LOCATION "1 < < Par {� }2ply L d Vv, ��dc i 1 n/ 9
PROJECT NAME (IF APPLICABLE) �Qlrl �_ ilaL_t 2 h S 1 u V1
PROPERTY OWNER 1)n\t J 1,Ayt, A P ii 1 ., fi n PHONE 4(,2r.(,i 3a I r & `i`1
ADDRESS A-1 R ✓�_ i7i �n Dyi (' tnJA- . 9 SS"D 1a2o
E-MAIL ciGt �i d C iAlriCf Q✓ WGC C" �t ✓V,a `i (,t inn FAX #
TAX ACCOUNT# SEC. TWP. RNG.
DESCRIPTION OF PROJECT OR PROPOSED USE (ATTACH COVER LETTER AS NECESSARY)
DESCRIBE HOW THE PROJECT MEETS APPLICABLE CODES (ATTACH COVER LETTER AS NECESSARY)
stir i�� J P i -,LI I i, O+ e l-S4-tr Lr C-+" C"11 i cl- C CAE'," I)
APPLICANT[ /a V,d lU1/)Jey1,n1 nor4 PHONE#'QL�,) -�:9 -b-4- l 1
ADDRESS i1 ri-1 i Pa rL` aQG! . , F, f b>r �i�t/{� , !�j x-, ;moo
CsA3 '►ie--, FAX #
CONTACTLl PERSON/AGENT LPL v. mniA -PAnAPHONE#(a- QJ
p�
ADDRESS 1,9-1 ( �Ca✓1� �i : t �G�Vyi6�PP� W24 GI �L2 ;)-o
E-MAIL UI/iytdbitVlr{Q rwo o�^tc�% . G%� , t'�oLr� 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 applica ' L n the behalf ftl weer as listed bel
SIGNATURE OF APPLICANT/A D 7 ./ //y
Property Owner's Authorization /
I, b1tyI'd ljt, (may 14- yo W , 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 purposes of inspection and pos ' endant to this application./GJ
SIGNATURE OF O DATE ` / Y 7 Z1 L�
I -'-Questions? Call (425) 771-0220.
Revised on 8122112 B - Land Use Application Page / of]