123 2ND AVE S 2ND FLOOR (2).._....__.___ _.....
/23 ZND AuE S
(Ztjo Fcao2)
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/ nP " 4, i' Z Af
CITY OF EDMONDS
BUSINESS LICENSE APPLICATION — COMMERCIAL ❑ Building
O Engineering
FEE: $125.00 a Fire
ng
CITY CLERK'S OFFICE, BUSINESS LICENSE DIVISION ❑ Police
4, r t04 TH
1215 AVENUE NORTH, EDMONDS, WA 98020 PHONE 425.775.2525
ehm 9-9 %+aTr OFFICE USE ONLY
BL#
Customer#
3305
SIC
Year
201 to
Class
13
SIiB
oa
Date Paid
I 5
TR#
0 -W7-3
Fee
117.5
Mailed
Deleted
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 writing NMN. Sign and return application with fee. Please advise of any change in status. New license required if
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 vicar rutici «air uiauiaii�
BUSINESS ADDRESS 123 2nd Avenue South
Street
MAILINGADDRESS 123 2nd Avenue South Q Edmonds. WA 08026
Street or PO Box # Suite # City, State, Zip Code
BUSINESS PHONE( 459 1 954-2227 WA STATE TAX ID # (UBI) 1 5 1 7 1 Q 6 1 1 ] 1 4 1 0
BUSINESS E-MAIL rrobinson5@gaig.com BUSINESS WEBSITE www.greatamericanbonds.com
BUSINESS OWNER / MAIN CONTACT Great American Insurance Company I t
Name Phone Number
PROPERTY OWNER Alcazar Enterprises LLC do Harry Hosey 1206 t 909-8054
Name Phone Number
EMERGENCY NOTIFICATION (For Premise Access in Emergency):
peweli-Inn Annho f AnC % GOn OGGQ
Last Name First r7ame MI Phorie�umber -- - - - -
Rowan Bob I 513r255-2488 .�
Last Name First Name MI Phone Number
NATURE OF BUSINESS (Provide a Detailed Description of Business Activities, Products & Servlces): Commercial surety bonds and underwriting and
SPACE ALTERATIONS TO BE MADE: YES -NO —
PREVIOUS BUSINESS AT THIS ADDRESS wy zna Avenue 3OUL11, Jlille 1
NUMBER OF EMPLOYEES 7 SQUARE FOOTAGE OF BUSINESS
PROPOSED OPENING DATE: 12/14/1 5
TYPE OF BUSINESS - PLEASE CHECK APPROPRIATE CATEGORY:
❑ CONSTRUCTION BUSINESS HOURS, 7 am to 4-30 pm l V
p( FINANCE, INSURANCE, REAL ESTATE
❑ LANDSCAPE, HORTICULTURAL DAYS OPEN: e"
❑ MANUFACTURING fr
❑ NON-PROFIT O SUNDAY (X WEDNESDAY I�
❑ RETAIL ❑XMONDAY g(THURSDAY /1
❑ SECONDHAND DEALER i
a SERVICES EkrUESDAY ❑,FRIDAY
a WHOLESALE O SATURDA¢
❑ OTHER
AMUSEMENT DEVICES ON PREMISES? YES NO-gIF YES, TOTAL NUMBER LIQUOR SOLD ON PREMISES? YES NO
GAMBLING? YES_ NOS -CIGARETTES SOLD ON PREMISES? YES NO--_X_-
FLAMMABLE OR HAZARDOUS MATERIALS USED OR STORED? YES NO X IF YES, PLEASE PROVIDE A LIST OF MATERIALS AND QUANTITIES:
PARKING SPACES ON SITE: TO A Ms 6 for our OffICCCESSIBLE SPACES FOR HANDICAP PARKING 2
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? YES_ NO
APPLICANT
w
NAME Angie Cordiann .ram CA,
Pri I d Nano uSlgrralure
TITLE Sr Unaggr"lfing Manager DATE /19115
2j�-
SOLE PROPRIETORSHIP
NAME
LAST FIRST MIDDLE INITIAL
ADDRESS
STREET SUITE/APT/UNIT # CITY/STATE/ZIP CODE
HOME PHONE( 1 DRIVERS LICENSE OR ID # & STATE
DATE OF BIRTH CITY/STATE OF BIRTH COUNTRY OF BIRTH
NAME
LAST FIRST MIDDLE INITIAL
ADDRESS
STREET SUITE/APT/UNIT # CITY/STATE/ZIP CODE
HOME PHONE( I DRIVERS LICENSE OR ID # &
DATE OF BIRTH CITY/STATE OF BIRTH COUNTRY OF BIRTH
PARTNERSHIP — PARTNER 2
NAME
LAST FIRST MIDDLE INITIAL
ADDRESS
STREET SUITE/APT/UNIT # CITY/STATE/ZIP CODE
HOME PHONE( 1 DRIVER'S LICENSE OR ID # & STATE
or
NAME OFCORPORATION. Great American Insurance Company FEDERALTAXO# 31-0501234
CORP.ADDRESS 301 E. Fourth Street Cincinnati, OH 45202 (513 )369-5000
Street Suite, Apt. Unit # City, State and Zip Code Phone Number
Principal
CORPORATE OFFICERS:
Last Name First Name MI Title DateotBirth Drivers License or Other ID#/State
Larson Donald D. President 8/5/1951 Ohio license - confidential
Witzgall David I. Treasurer 6/29/1959 Ohio license - confidential
Rosen Eve C. Secretary 6/4/lg-S9 Ohio license - confidential
LOCALCONTACT Cordiano Angie Sr. Underwriting Manager /
Last Name First Name MI Title Dateof Birth ✓
C o (L O r A A,) O + ; �;;� IDS 14 , ( 425 ) 954-2208
CITY USE ONLY:
BUILDING DEPT. APPROVE 0 DISAPPROVE DA
OCCUPANT LOAD BUILDING PERMIT
SIGNATURE
OCCUPANCY GROUP
COMMENTS
ENGINEERING Q APPROVE DISAPPROVE DATE SIGNATURE
FIRE DEPT. 0 APPROVE 0 DISAPPROVE DATE SIGNATURE
U.F.I.R.
COMMENTS
PLANNING DEPT. Q APPROVE Q DISAPPROVE DATE SIGNATURE
ZONING CODE CONDITIONAL USE PERMIT
COMMENTS
POLICE DEPT. APPROVE Q DISAPPROVE DATE SIGNATURE
COMMENTS
Floor Plans for: SEA1232A-02
page 1 of 1
November 11, 2015
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