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20520 77TH AVE W.PDFIIIIIIIIIIII 6512 20520 77TH AVE W Ao VvT y BUSINO LICENSE APPLICATION CITY OF EDMONDS TH 250 5TH AVENUE NOR EDMONDS, WASH. 98020 TEgfA(2.0"7 -250 Et: i ILE' INSTRUCTIONS I . PRINT APPLICABLE LICENSE CLASS, FEE AND PENALTY PAID IN ANNUAL FEE BOX AT RIGHT. PENALTY DUE ON RENEWALS RECEIVED BY CITY CLE ' RK AFTER FEBRUARY 15. 2. NEW BUSINESS: COMPLETE ALL LICENSE APPLICATION BOXES. LIC. RENEWAL: REVIEW LICENSE I NFORMATION BELOW. PRINT CORRECTIONS AND ADDITIONS AT RIGHT. 3. SIGN AND RETURN APPLICATION WITH FEE (AND PENALTY). 4. LICENSE WILL BE MAILED TO YOU UNLESS YOU ARE NOTIFIED �l TO APPEAR FOR APPLICATION REVIEW. . LICENSE RE NEWAL REVIEW BELOW INFORMATION, PRINT CHANGES AT RIGHT r2. APPLICANT NAME SOCIAL SECURITY NO. DATE OF BIRTH PLACE OF BIRTH HOME ADDRESS ANNUAL FEES TYPE BUS. CLASS FEE PENALTY HOME A, slO.00 $ 5.00 SMALL 8 15.00 7.50 *GENERAL C 50.00 25.00 3. BUSINESS IDENTIFICATION BUSINESS NAME NATURE OF BUSINESS BUSINESS PHONE WASH. STATE TAX NR. EMPLOYEES I ORGAN. JOCCU I PANCY 'OVER 10 EMPLOYEES, OR EMPL WORK .OVER 120 MAN -MONTHS PER YEAR. FEE PAID PENALTY PAID TYPE ORGANIZATION IF BUSINESS IS: TYPE CAPACITY C HOTEL/IVIOTEL L NR OF ROOMS/UNITS 0 C.- CORPORATION APT.BLDG. A NR OR APTS D L LTD. PART OFFICE BLDG. 0 NR OF OFFICES E P PARTNERSHIP RESTAURANT R NR OF SEATS S S SOLE OWNER HOSP./NURS. HOME H NR OF BEDS \1 I . SCHOOL . S NR OF STUDENTS. 4. BUSINESS ADDRESSES BUSINESS ADDRESS LICENSE MAILING ADDRESS 5. EMERGENCY NOTIFICATION NAME AREA TELEPHON (1) (2) OFFICIAL USE ONLY U.F.I.R. CODE BLDG. PERMIT OC C.U; PERMIT LAND CITY CLERK'S SIGNATURE [:] APPROVED [:] DISAPPROVED DATE FORM CC -I (10,176, STAFF ACTION �REVERSE APPL. NO.: — - SIDE DATE:.(-i (APPLICATION FOR: NEW LIC, LICENSE qz BUS, 1:1 RENEW YEAR I C�TSSJ YEAR I LIC. EFFEC. DATE I REASG. LIC. NO. I SPIC A , DATE PRINT 'X' Kill bb-,4.A ?I I N SPEC BOX F R I UE OF AID PENALTY PAID C 0 R R E C T E 1) LICENSE WITH 'LC' ACTION. . �ILICENSE APPLICATION AND CHANGES PLEASE PRINT CLEARLY LOCIAL SECURITY NUMBER � 13 ill I /.,/I z I �'7e, -I /3. BUSINESS IDENTIFICATION BUSINESS NAM E (FULL) 1 14,1 Iff , NATURE OF BUSINESS (DRUG STORE, CPA, ETC) 1�,BUSINESS PHONE WASH. STATE TAX NR. ANTICIPATED TYPE OF OCCUPANCY (REGISTRATION) INR. EMPLOYEESI ORGAN. TYPE CAPACITY ENTER APPLICABLE TYPES AND C APACITY I t ""5. EMERGENCY NOTIFICATION (IN EVENT OF FIRE. BURGLARY, ETC.) LAST NAME, FIRST INITIAL' AREA CODE TELEPHONE (1) ff, �ti kly, e, Zi L I 1 6 :�?, e), 6 )Fj 2,1,2, ;; LA�T NAME, FIRST INITIAL AREA CODE TELEPHONE ALJ)I2T4l4t'l 1#1 - ),2,37tj,2I /, _),I -� 5S OFFICIAL USE ONLY : PRIM. UNITS BUS. BLDG. �RMIT j_[0 U.FA.R. jjf;C�UTP.G P.. CODE IS �j 10,0, USE'PeRMLI —1 ZOANP - r?-,� 117, N 1:) ) k,, BUS. TITLE RE-rur,', 'q TO CITY CLERK DATE PAID FFI.QIAL W5E QNLY LICENSE NUM R LA NEW BUS LB RENEWAL LC CHANGE LID DELETE DATE OF BIRTH PLACE OF BIRTH MO. DAY I YEAR CITY STATE L9 HOME ADDRESS [:] APPROVED [:] DISAPPROVED DATE FORM CC -I (10,176, STAFF ACTION �REVERSE APPL. NO.: — - SIDE DATE:.(-i (APPLICATION FOR: NEW LIC, LICENSE qz BUS, 1:1 RENEW YEAR I C�TSSJ YEAR I LIC. EFFEC. DATE I REASG. LIC. NO. I SPIC A , DATE PRINT 'X' Kill bb-,4.A ?I I N SPEC BOX F R I UE OF AID PENALTY PAID C 0 R R E C T E 1) LICENSE WITH 'LC' ACTION. . �ILICENSE APPLICATION AND CHANGES PLEASE PRINT CLEARLY LOCIAL SECURITY NUMBER � 13 ill I /.,/I z I �'7e, -I /3. BUSINESS IDENTIFICATION BUSINESS NAM E (FULL) 1 14,1 Iff , NATURE OF BUSINESS (DRUG STORE, CPA, ETC) 1�,BUSINESS PHONE WASH. STATE TAX NR. ANTICIPATED TYPE OF OCCUPANCY (REGISTRATION) INR. EMPLOYEESI ORGAN. TYPE CAPACITY ENTER APPLICABLE TYPES AND C APACITY I t ""5. EMERGENCY NOTIFICATION (IN EVENT OF FIRE. BURGLARY, ETC.) LAST NAME, FIRST INITIAL' AREA CODE TELEPHONE (1) ff, �ti kly, e, Zi L I 1 6 :�?, e), 6 )Fj 2,1,2, ;; LA�T NAME, FIRST INITIAL AREA CODE TELEPHONE ALJ)I2T4l4t'l 1#1 - ),2,37tj,2I /, _),I -� 5S OFFICIAL USE ONLY : PRIM. UNITS BUS. BLDG. �RMIT j_[0 U.FA.R. jjf;C�UTP.G P.. CODE IS �j 10,0, USE'PeRMLI —1 ZOANP - r?-,� 117, N 1:) ) k,, BUS. TITLE RE-rur,', 'q TO CITY CLERK DATE PAID FFI.QIAL W5E QNLY LICENSE NUM R LA NEW BUS LB RENEWAL LC CHANGE LID DELETE DATE OF BIRTH PLACE OF BIRTH MO. DAY I YEAR CITY STATE L9 HOME ADDRESS APPLICATION ot. FU T10 City of Edmonds for EASEMENT NO - ------------------------------------ SIDE SEWER PERMIT .......... sa- NEW CONSTRUCTION's REPAIRS E] LID NO. L31 ------ ASMT. NO. -LUC 77�e> OWNER ....... -V -3 ---- CONTRACTOR ... 7 .......... ...... ----- ----- ........... ---------- - .... ... ................................................. PERMIT NO . . ................. JOB ADDRESS ---- LEGAL DESCRIPTION: LOT NO. -------------------------- BLOCK NO - ------------------------------------ -1 .................................................................................................................................................................. NAME OF ADDITION CS ----------------------------------------- --------------- Approved: kj DATE By .................. ....... ......... ly ---- NOTICE: No warranty of accuracy. The information shown on the attached map(s) was compiled for use by the City of Edmonds, its Employees and Consultants. The City of Edmonds does not warrant the accuracy of anything set forth on these map(s). Any person or entity requesting a copy should conduct an independent inquiry regarding the information shown on the map(s), including, but not limited to, the location of any sewer stub shown. Such sewer stubs may or may not exist and may or may not exist at the location shown.. Neither the City of Edmonds nor its employee-s or officers s-hall be liab-l-e for the information given on this map(s), nor for any one representation provided based upon said map(s). CITY OF EDMONDS - SIDE SEWER PERMIT WATER -SEWER DEPARTMENT PERMIT Call 775-2525 for side sewer inspections RFFORE covering any portion of the construction. Inspection will be provided within 24 hours after requst. NO Sat., Sun., or holiday inspection .) ADDRESS LOCATION OF CONSTRUCTION ....... PROPERTY LEGAL DESCRIPTION ............. ��47_4- ......................... ........................................................................ .............................................................................................................................................................................................................................................................. ---------------------------------------------------------------- OWNER AND/OR BUILDER __-- ------ ................. CONTRACTOWS NAME & ADDRESS ........... - -------- Ydssion is granted ------------ ��2 , ....... ......... 19-71Z, for repair and/or connection of a side sewer to the city sanitary 6n in accordance with City of Edmonds ordinances. sewer ATTENTION IS CALLED TO THE FOLLOWING: NOTE No. 1—The owners of the property may obtain a Permit to construct sewer inside Property line. A licensed Side sewer contractor must be employed to construct side sewer in street area. Do not cover any Portion of sewer hefore it has been inspected. NOTE No. 2—All work Performed in city right-of-way requires an Invasion Of Right-Of-WaY Permit obtainable from the City Engineer's office. NOTE No. 3--Obtain full information regaxding Ordinance 11.16.030 and Regulations governing side sewers when you get permit. NOTE No. 4—Top, of side sewer must have at least 30 inches coverage at property line and 12 inches inside property line; minimum grade of 2%. No bends in grade sharper than % will be permitted. NOTE No. &--Trenches in street must be water settled and surface of street restored to original condition. Contractors shall be responsible for failure due to improper work which may develop within one year Of completion. NOTE No. 6--It is unlawful to alter or do any other work than is provided for in the Permit, or to do any work on the main sewer or its appurtenances except to in- sert the pipe into the wye. DISAPPROVED El Date ........ It. BY -----_---_-- Date ............... . .......... By 01 -- - - - --------- - ---- --------- ................ -at.. __ - * .... q ..... I &1�1� APPROVED Date ... --------------- /Bydg::� �_ ---------- B_ 5Y ------------ ............ Mmnarks: ................ .............................. . .......................................................... ------------ -------------------- .................................................................................................... ..................................................................... . ................................... .................................................... . .................................. . ............................................. ......... BOTH Permit Copies MUST Be Siped By Owner of Firm P%41ormin g Construction PRIOR To Request Fo Iction ",A. - !ction .... hereby certify that the side sewer installation constructed under this permit w)as installed in accordance with all governing ordinances of the City of Edmonds. Datedthis ---------------------------- day of ................................................................. ) 19 ......... V Check BEFORE you dig for: Water [-], Gas El, Telephone 0, Power 0, Sewer o, Other E] Nt V .1 APPUCATION Tie City of Edmonds for EASEMENT NO. --- ------------------- ------------------- SIDE SEWER PERMIT NEW CONSTRUCTION JN� REPAIRS LID NO - ------------------ - ASMT. NO - -------------- OWNER ...... '777�c --------- -* - - ------- PER -MIT NO. !a!7,9 ---- --------- ------------------------------------------------- CONTRACTOR ------------------------------------ ;-(.- r,4,jzc'j ------------ JOB ADDRESS --------------- 2-2 -------- -- ------------- LEGAL DESCRIPTION: LOT NO - ------------------ ------------------- BLOCK NO - --------------- - ------------------ ......................................................................... I ---------------------------------------------------------------------------------------- NAME OF ADDITION.. ... ........ X-- 'eJ-5 .......... I J� 5' Approved: DATE-------------------------------------------- By -------------------