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21006 80TH PL W
CITY of EDMONDS INESS LICENSE 'APPLICATION
0.,
C
Civic Center Ed monds, Washingtor 020
Clerk
STREti FILE
City Phone 775-2525
INSTRUCTIONS:
CLASSIYEARI
LIC. EFFEC. DATE IRE
SG. LIC. NO.
�PEC
4 All items must be completed
/1
xv
or application will not be ac-
RECEIPT NO
DATE P I
A&
RINT 'X'
cepted.
I -, �/ 1. S f,
IN SPEC. BOX
El
- Sign and return application
FEE PAID
PENALTY, PAID
FOR ISSUE OF
CORRECTED
with fee. Renewals received
I I I
LICENSE WITH
'LC' ACTION.
after February 15 must pay
penalty in addition to fee.
NEW'BUSINESSES AFTER
E LICENSE NO.
ANNUAL FEES PENALTY AFTER FEB. 15
,,-HOME OCCUPATION
-_,�i 0.00 (A) ADDITIONIAJ,415.00 0
SMALL >ES S
$1 00
10 or
Business ' 10 or
mo!rq,eWp11cyees
JULY 31, 1/2 FEE. (PLEASE MAKE ANY NECESSARY CHANGE
ADDITIONAL $7.50 0
AL $25.00 0
.-e-1'TEW APPLICATION (LA)
• RENEWAL (LB)
• CHANGE (LC)
0 DELETE (LD)
NANI; OF FIRM BUSINESS PHONE 3 NO. OF EMPLOYElfr%
*v 7,0,(3
MAILING ADDRESS NATURE OF BUSINESS
oo6 0'A fh LI)c 6- S - W ' 79;,�'-
ou
EDM07)DS, LSA
BUSINESS ADDRESS C).;)-1!5QL INPIVIDUAL PARTNERSHIP CORPORATION
00.14 114-;�L -
Q 1006 . 0 P L 4A) (S) (P) (C)
QWNERS NAME HOME ADDRESS
.U-Q NJEJ? H 0 UF,. 16ATE_QF BIRTH PLACE OF BIRTH SOCIAL SECU TY
7-7-5-7,195- 1-5 _/1 - V 9 1 � I L!�j v W j
EMERGENCY NOTIFICATION: (1) NAME & TELEPHONE to 7x? L!5
(PLEASE LIST TWO) (2) NAME & TELEPHONE I -en iv 7 Z,�F' - __�ZL Z,:L
WASHINGTON STATE TAX NO. V APPLICANT'S SIGNATUR
DO NOT WRITE BELOW THIS LINE
STAFF REVIEW: FILL IN LAND USE CODE, UFIR NUMBERS, ZONING, ETC. CHECK APPROVAL OR
DISAPPROVAL, DATE, AND SIGN. IF DISAPPROVAL, PLEASE COMPLETE "COMMENT-,
SECTION. ROUTE TO NEXT DEPARTMENT ON LIST.
PLANNING DEPARTMENT DATE— LAND USE CODE ZONING CODE
IkAPPROVE 0 DISAPPROVE
SIGNATURE
CONDITIONAL USE PERMIT
COMMENTS FFI
B�U�DING DEPARTMENT DATE
Building
0 Hotel/Motel
(L)
21 APPROVE 0 DISAPPROVE SIGNATURE pje_ev��
Permit
0 Apt. Bldg.
(A)
r I I I I I E3 Office Bldg.
(0)
Occupancy
0 Restaurant
(R)
COMMENTS:
Group
0 Hosp/Nurs Home
(H)
CAPACITY: (NO. UNITS, APTS., OFFICES, SEATS, BEDS, STUDENTS)
0 School
(S)
FIRE DEPARTMENT DATE ':Jr -,1-2- 911
U. F. 1. R.
_XAPPROVE El -DISAPPROVE SIGNATURE "�_ C0_2�
COMMENTS:
POLICE DEPARTMENT
DATE SIGNATURE
V�IAPPROVE 0 DISAPPROVE
COMMENTS:
PUBLIC WORKS DEPARTMENT
EJ APPROVE 0 DISAPPROVE
>
DATE SIGNATURE
- 1.r,
COMMENTS: 4 q,21 - 0.� /a
PLEASE RETURN TO CITY CLERK
CITY OF' EDMONDS
ENGINEERING DEPARTMENO
8_rRS
(rA
'M"2R RIGHT-OF-1,'!AY CONSTRUCTION PERMIT
a in DupZicate)
5 Cc=olete A & rd Subm,,
Permit to be issued to: <r, C. f4� c G n.,
For* work at: (address or vicinity) lb 0
Type of work to be done: rk E m-e o L
(Attach Drawing 1%"hen Applicable)
N
Time Required Start: Finish:
Owner: K C.�, E G 0
Name
Mailing Address
City State Telephone Number
Cont rac tor: u- ki (�7
Name State License Number
t., A -
Mailing Address
city State Telephone Number
INDE-IfrITY: Applicant -understands and by his signature to this application, agrees
to hold the City of Edmonds harmless from any injuries, damages or claims of any
kind or description whatsoever, foreseen or unforeseen, that may be made against
the applicant or the City of Edmonds, or any of its departments or employees,
including but not limited to the defense of any legal proceedings including defense
costs, court costs, and attorney fees by reason of granting this permit.
Upon issuance of this permit, the contractor is responsible for workmanship and
materials for a period of one year following the final inspection and acceptance
of the restoration by the Engineering Department.
'Work subject to inspection and restoration in accordance with City Code. A
24-hour notice is required ion by the Engineering Department.
Call 775-2525. )(0-upL,0
Signature:
Owner or Agent Date Signed
DO NOT WRITE BELOW THIS LINE (To be conTZeted by Is8uing Agency)
Permit Issued (Date)A
Permit Numb er_7] 7— ;,)03
Fee: Bond:
Time Authorized:
E
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'5 ac -F I C)N 514"= 1'-0'
CITY
OF
EDMON
DS
r-ATE
45 NO -MD
PVD.
OWG, No.
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