114 2ND AVE S STE 108IIIIU liq ztjo Au- f Xrg /08
CITY OF EDMONDS
BUSINESS LICENSE APPLICATION - COMMERCIAL
FEE: $125.00
ion. rw,Io CITY CLERK'S OFFICE, BUSINESS LICENSE DIVISION
121 5TII AVENUE NORTH, EDMONDS, WA 98020 PHONE 425.775.2525
Building
i Engineering
L Fire h
Planning
c Police
INSTRUCTIONS: Please complete the application in full and attach the required floor plan. Middle initial or name required of all parties concerned. If no
middle name, please Indicate by wflUng NMN. Sign and return application with fee. Please advise of any change In status. New license required It
business changes location or ownership. Notification to City of Edmonds required if business closes. License expires December 31" each year, Renewal
must be submitted prior to January 31" to avoid late fees.
BUSINESS NAME -514 ILO'6 @—�.1 �''+ f { :5 0 7�- 0 A �
BUSINESS ADDRESS d �
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Street
Suite fi
City, State, Zip Code
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MAILING ADDRESS
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Street or PO Box A
Suite #
City, State, ZI p Code
BUSINESS PHON51_4 4 `- � 1 1 7
WA STATE TAX ID # (UBI) ( ® ,
0
BUSINESS EMAIL ':W R'..d
1J F J 4 01- 4 tt1 v
BUSINESS WEBSrTE
BUSINESS OWNER I MAIN CONTACT
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Name
Phone Number
EMERGENCY NOTIFICATION (For Premise Access InEmmrge cy): f�\
'O ,. c c9 A . a ¢z � 1, � XT .,w a.4 O _ 9
Last NAmo First Name MI Phone Number
{ 1
Last Name First Name MI Phone
�Number
NATURE OF BUSINESS (Provide a Detailed Desaiption of Business ActiyIdes. Products & Services) r f ) C7PI e Ki
SPACE ALTERATIONS TO BE MADE YES_ _ zNO� DESCRIPTION
PREVIOUS BUSINESS AT THIS ADDRESS---J) _V�Q- '�a-Y »°L
NUMBER OF EMPLOYEES If SQUARE FOOTAGE OF BUSINESS
TYPE OF BUSINESS- PLEASE CHECK APPROPRIATE CATEGORY:
CONSTRUCTION
'I
FINANCE, INSURANCE, REAL ESTATE
LANDSCAPE, HORTICULTURAL
MANUFACTURING
NON-PROFIT
1
RETAIL
-i
SECONDHAND DEALER
SERVICES
WHOLESALE
OTHER
PROPOSED OPENING D(�ATF";'_!�
BUSINESS HOURS 4 • �� _' �' 4r✓
DAYS OPEN*
SUNDAY >OVEONESDAY
)XMONDAY P&THURSOAY
V&4UESDAY 'KFRIDAY
• SATURDAY
AMUSEMENT DEVICES ON PREMISES? YES NO, t-IF YES. TOTAL NUMBER LIQUOR SOLD ON PREMISES? YES NO_�
GAMBLING? YES— N0--$�-CIGARETTES SOLD ON PREMISES? YES NO__
FLAMMABLE OR HAZARDOUS MATERIALS USED OR STORED7YES NO—X IF YES, PLEASE PROVIDE A LIST OF MATERIALS AND QUANTITIES:
PARKING SPACES ON SITE: TOTAL SPACES o%QT ACCESSIBLE SPACES FOR HANDICAP PARKING
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? YES NO
APPLICANT C °o
Pnfu ama Signature
TITTLE-- t-> 'G1_ rP N � :%ji DATE 6- - a6
IApplications maybe mailed In with a check, brought in person, faxed tG 425-771-0266 or emailed to business.license@edmandswa.aov
with a valid phone number. we will call you for a Visa or MasterCard payment. ,
OY-- C-P -2- 1 - � �
n y, SOLE PROPRIETORSHIP
NAME`_ U °
tAS7 FIRST MIDDLE INITIAL
ADDRESS, ll�' Na 111 d _ l 6 I6R, � - l � ij ; tq �a L4. �
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�ccSTRT )/Gy SUrrFJAPTIUNIT # CITYIS/T�A�fTEIZIP CODE ( q
HOME PHONE( w_ � � } ���9 v (� F( �gRIveRS LICENSE OR 109& STATE
�y A�jgP.
DATE OF BIRTH Q6 �/—? j `A `i C�TYISTATE OF BIRTH C'+,fit 7 Y (Is COUNTRY OF BIRTH K� �
PARTNERSHIP- PARTNER 1
NAME
LAST FIRST MIDDLE INITIAL
ADDRESS _
STREET SUITEIAPTIUNIT # CITYISTATE/ZIP CODE
HOME PHONE( 1 DRIVERS LICENSE OR ID # & STATE
DATE OF BIRTH CITYISTATE OF BIRTH COUNTRY OF BIRTH
PARTNERSHIP — PARTNER 2
NAME -
LAST FIRST MIDDLE INITIAL
ADDRESS.-__
STREET SUITEIAPTIUNIT # CITYISTATEIZIP CODE
HOME PHONE( DRIVER'S LICENSE OR ID # & STATE
WKI'UKAI IVI'i/ LLG or YLLL;
NAMEOFCORPORATION_ _,. __ FEDERALTAXID#
CORP.ADDRESS
Street SWIG, ApL Urdl# City, State and Zip Code Phone Number
CORPORATE OFFICERS.
Last Name First Name MI Title Dateol9i* Dmer•s License or Other D#IStale
LOCAL CONTACT
Last Name First Name MI Tille [WeslBirth
Driver's License or Other ID# I State Phone Number
CITY USE ONLY:
BUILDING DEPT
® APPROVE
0 DISAPPROVE DATE
SIGNATURE
OCCUPANT LOAD
BUILDING PERMIT
OCCUPANCY GROUP
COMMENTS
ENGINEERING
APPROVE
DISAPPROVE DATE
SIGNATURE
FIRE DEPT
APPROVE
DISAPPROVE DATE—
_SIGNATURE —` -
U.F I.R.
COMMENTS_
-
PLANNING DEPT
Q APPROVE
Q DISAPPROVE DATE
SIGNATURE
ZONING CODE
CONDITIONAL USE PERMIT_—__-_
- _ COMMENTS^,—
POLICE DEPT d ED APPROVE DISAPPROVE DATE SIGNATURE
COMMENTS_—._ -- _--.
�dDTR 6