170 W DAYTON ST STE 204 (2)/70 LJ DAITON CT- ;26LI
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CITY OF EDMONDS
SINESS LICENSE APPLICATION- COMMERCIAL
FEE: $125.00
CITY CLERICS OFFICE, BUSINESS -LICENSE DIVISION
�n�• 189� 121 5TH AVENUE NORTH, EDMONDS. WA 95020 PHONE: 425.7752525
OFFICE USE ONLY
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1NSTR mats: Please complete the application In full and attach the requited floor plan. Middle initial or name required of all
parties cdncerned. N no middle name, phrase indicate by writing NMN. Sign and return application with fee. Please advise of
Any change in status. New license required if business changes location or ownership. Notification to City of Edmonds requited
N'business bloses.
BUSINESS ADDRE
MAILING ADDRESS 1 eA t1tv hm c P j 6-, SJ -4. " 0 , VVJ4 WnV
Street or PO ty _) Suite No. City. State and Zip Code
BUSINESS PHONE NO. (`i�4�7 1 bT 1912) WA STATE TAX Iq NO. (UBI NO.) p-3-A
BUSINESS E-MAIL
PROP60YOWNE
EMERGENCY NOTIFICATION (For Premise Aoceas In Emergency):
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Last Name First Name MI Phone No. j �,
�y- . �1 VN (425 1 `r1 -- 1 v7 11
Last Name rst Name MI Phone No.
NATURE OF BUSINESS L-1 Uiiewj 'm r
NUMBEROF•EMPLOYEES SQUARE FOOTAGE OF BUSINESS SPACE �_� I U� S •r•
TYPE OF BUSINESS - PLEASE CHSCK THE•APPROPRIAW CATEGORY`:
O CONSTguanON ' O• FINANCE,' INSURANCE.AEAL ESTATE. • O U1WDS,CAPE, HORTICULTURAL O MANUFACTURING O (NON-PROFIT
.o Reml,* :d SEWhbHAND 06M" XSERVICES a WHOLESALE o.OTHER
AMUSEMENT DEVICES"OMPREMISES? ' .O Y9S NO . 1F YES. TOTAL NUMBER
LIQUOR SOLD ON PREMISES?:• O YES. NO.' dweuw? OYES XN0 . CIGARETTES SOLD•ON PREMISES? DYES )NO
FLAMNU3LE OR HAZARDOUS MATEMAL$ USED OR STORED?: DYES NO IFYES, PLEASE PROVIDE LIST OF MATERIALS AND QUAN11TIES:
PROP08ED OPENING OAXOF BUSINESS N(r,�:.2b ::XQ12- BUSINESS HOURS &)Az r7 ann
DAYS OPEN O SUNDAY 1AOND,�Y XTUESOAY %%WEDNESDAY j(THURPDAY )(FRIDAY -O SATURDAY
PAMONG SPACES ON SITE: TOTAL 4 1 2. ACCESSIBLE FOR PERSONS WITH DISABILITIES
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TOs PERSONS WITH OISA8ILITIES?. *((YES ONO i
PREVIOUS BUSINESS USE AT THIS ADDRESS co t'C
SOLE PROPRIETORSHIP
NAME L/ � e AS
Loa First
MI
ouau APL RM, Utut No. City, State and Zip Code
HOME PHONE NO. j_��CM��AND,�STATEIOFOIRT
OLNO. (DRIVERS LICENSENO.) OR OTHER ID NO � DATE OF BIRTH 1 l LLl H4�1 ( COUNTRY OF 81"
PARTNERSHIP - PARTNER 1
Last- Fib
ADDRESS
Street Apt. No.. Unit No. C(Iy, State and Ztp Code
HOME PHONE NO.( t OOL NO. (DRIVERS LICENSE NO.) OR OTHER ID NO.
DATE OF BIRTH .CITYAND STATE OF BIRTH COUNTRY OF BIRTH
PARTNERSHIP • PARTNER 2'
NAME .
1� - •Fl�st Mi.
ADDRESS
Street Apt. No.. Unit No. City, S1ato and Z(P Code
HOME PHONE NO.( ) . DOL NO. (DRIVERS LICENSE NM) OR OTAER'ID NO.
DATE OF BIRTH CxTY AND STATE OF BIRTH COUNTRY OF BIRTH
a.vnrwchiam .
NAME OF CORPORATION FEDERAL fAX ID NO.
CORP. ADDRESS PHONE NO.(_ I
$treat Suite. Apt. lhdt No. City. State and Zip Code
CORPORATE• OFFICERS:
Last Name Fatt Name MI Title Date of Blhh DOL Nd. (D fivers Liomse No.) or Other ID No.,
LOCAL CONTACT ( t
Last Name RM Name Mi . Title Photte No. DOL No. (OrKwo LIa. Nq.) or Other ID,No.
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BUI�DING,•OEPT O'APPROVE O DISAPPROVE DATE SIGNATURE .
OCC UMNT LOAD_ BUI DING PERMVI- �OOCUPANCY GROUPX.
COIaMENTS M1
'FIRE OEPT. 'O APPROVE O DISAPPROVE DATE SIGNATURE '
POLICE DSPT. O•APPROVE . 0 DISAPPROVE DATE SIGNATURE ' '
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Dayton Street
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