Land Use ApplicationCity of Edmonds
Land Use Application
❑ ARCHITECTURAL DESIGN REVIEW
❑ COMPREHENSIVE PLAN AMENDMENT
❑ CONDITIONAL USE PERMIT
❑ HOME OCCUPATION
❑ FORMAL SUBDIVISION
❑ SHORT SUBDIVISION
CI LOT LINE ADJUSTMENT
PLANNED RESIDENTIAL DEVELOPMENT
OFFICIAL STREET MAP AMENDMENT
STREET VACATION
REZONE
SHORELINE PERMIT
VARIANCE / REASONABLE USE EXCEPTION
OTHER:
DEVELOPMENT SERVICES
COUNTER
I' _
FILE # P L-NaOIg 0bQ ZONE Q D V
DATE I I 13o/ 15 REC'D BY t,G
FEE
HEARING DATE
RECEIPT #
❑ HE ❑ STAFF ❑ PB L' ADB ❑ CC
• PLEASE NOTE THAT ALL INFORMATION CONTAINED WITHIN THE APPLICATION IS A PUBLIC RECORD 0
PROPERTY ADDRESS OR LOCATION Z� 3 L L. I s�.i n�� 44 ��y •7[�
PROJECT NAME (IF APPLICABLE)
PROPERTY OWNER -SAM0--M)AQ,,A J f' L- C _ PHHONE #
ADDRESS S)tp <4_/1ue- A tu a ynsl co A `Ira
E-MAIL
TAX ACCOUNT #
FAX #
SEC. TWP. RNG.
DESCRIPTION OF PROJECT OR PROPOSED USE (ATTACH COVER LETTER AS NECESSARY)
t
DESCRIBE HOW THE PROJECT MEETS APPLICABLE CODES (ATTACH COVER LETTER AS NECESSARY)
APPLICANT si .,, I SG In f . r r PHONE # an CB l
ADDRESS k (y !,fib' A U r-- 5 c: v✓!L7✓Lc_� LJ�% ✓� cl Y J -�
E-MAIL
FAX #
CONTACT PERSON/AGENT 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 its lts a ith submitted are true and correct to the best of my knowledge
and that I am authorized to file this applicatiot 4tehadf81 I UMICIW.
SIGNATURE OF APPLICANT/AGENT DATE 7
Property Owner's Authorization
I, , certify under the penalty of perjury under the laws of the State of
Washington that the following is true and correct statement: I have authorized the above Applicant/Agent to apply for the
subject land use application, an g ant my permission for the public officials and the staff of the City of Edmonds to enter the
subject property for the purpo s inspection and postii pplication.
SIGNATURE OF OWNER DATE `
Questions? Call (425) 771-0220.
Revised on 8122112 - B - Land Use Application Page 1 of 1