Land Use Application.pdfCity of Edmonds �
Land Use Application
G ARCHITECTURAL DESIGN REVIEW
❑ COMPREHENSIVE PLAN AMENDMENT
❑ CONDITIONAL USE PERMIT
'>_C HOME OCCUPATION
❑ FORMAL SUBDIVISION
❑ SHORT SUBDIVISION
❑ LOT LINE ADJUSTMENT
❑ PLANNED RESIDENTIAL DEVELOPMENT
❑ OFFICIAL STREET MAP AMENDMENT
❑ STREET VACATION
❑ REZONE
❑ SHORELINE PERMIT
❑ VARIANCE / REASONABLE USE EXCEPTION
❑ OTHER:
• PLEASE NOTE THATALL INFORMATION CONTAINED WITHIN THE APPLICA TION IS PUBLIC RECORD •
PROPERTY ADDRESS OR LOCATION I H %, ayn
PROJECT NAME (IF APPLICABLE)
PROPERTYOWNER Kfti'i(-V -�aA r1Y -F ` 4RAK,K,C,0*Y HONE#
ADDRESS
E-MAIL ��� �`� o l^ JO• �:� FAX# '
TAX ACCOUNT # 00." SCg3cc000 SOP- SEC. TWP. RNG.
DESCRIPTION OF PROJECT OR PROPOSED USE (ATTACH COVER LETTER AS NECESSARY)
To V, C 50,)4CP Q �P roof-pM lh � C</-� �fJ�
75 t4 ('-f_ n Oro I',A S-ee ,'r, /s / 9P-4 _/ /_
DESCRIBE HOW THE PROJECT MEETS APPLICABLE CODES (ATTACH COVER LETTER AS N'tCESSARY)
APPLICANT ( t i} Zy PHONE #
ADDRESS (I � G Sen- �/':`. I. (�Cr,L—
r.
E-MAIL K-q flirt_. /-(-) •---I
CONTACT PERSON/AGENT
ADDRESS
E-MAIL
M FAX #
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 application on the behalf of the owner as listed below.
SIGNATURE OF APPLICANT/AGENT i
Property Owner's Authorization
DATE f✓ / c
Ar" 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 posting attendant to this application.
SIGNATURE OF O\1 DER \ - DATE � / > I l ( C)
Quest�ns \ all (425) 771-0220.
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