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21319 80TH AVE W
STAFF A�CTION��
6y BIJSI,,'Irvt��SS LICENSE APPLICATION PPL 0
EREVERSE
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S: APPL. NO.:
CITY OF EDMONDS SIDEI
250 5TH AVENUE NORTH DATE. d 1/frl
EDMONDS, WASH. I C :A F:R:: :ENSE
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98020
TELF�,EHON,E (2 1 6) 775-2525
B, S
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INSTRuc-rIONS
1. PRINT APPLICABLE LICENSE CLASS. FEE AND PENALTY PAID
IN ANNUAL FEE BOX AT RIGHT. PENALTY DUE ON RENEWALS
RECEIVED BY CjT'Y' CLERK AFTER FEBRUARY 15.
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ANNUAL FEES
TYPE BUS.
CLASS FEE PENALTY
HOME
SMALL
A $10.00 S 5.00
B
1
rC
'GENERAL
15.00 7.50
, C 50.00 25.00
*OVER 10 EMPLOYEES, OR EMPL WORK
OVER 120 MAN -MONTHS PER YEAR
CLASS FEE PAID PENALTY PAID
LICENSE RENEWAL
REVIEW BELOW INFORMATION. PRINT CHANGES AT RIGHT.
NAME 77- GHT
NO.
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0AIL Of- BIRTH
LAU r olmirl
iHOME ADDRESS
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NATURE OF BUSINESS
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IF BUSINESS IS TYPE CAPACITY
HOTEL/MOTEL L Nf? Of: ROOms
C CORPORATION UNITS
APT.BLDG. A NR OR APTS
L LTD. PAR I* OFFICE BLDG. 0 NF? OF OFFICES
-_f,PARTNERSHIP
RESTAURANT R NR OF SEATS
S SOLE OWNER
HOSP./NURS. HOME H NR OF BEDS
SCHOOL
S NR OF STUDENTS
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NOTIFICATION
NAME �_AREA TELEPHONE
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RECEIPT NO.
DATE PAID
PRINT W
IN SPEC. BOX
FEE PAID
PENALTY PAID
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FOR ISSUE OF
CORRECTED
LICENSE WITH
'LC' ACTION.
LICENSE APPLICATION AND CHANGES -
PLEASE PRINT CLEARLY
FLT�ST N—AME. FIRST INITIAL _,'URITY NUMBER
L. . I
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DATE OF BIRTH
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BUSINESS NAME (FULL)
NAT
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WASH. STATE T R.
(REGISTRATION)
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4. BUSINE S ADDRESS
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APT. NO.
LICE SE AILII
BLDG. NUMBER
STREE
APT. NO.
C IrT Y
STATE ZIP CODE
Lz I/) I,. J (A "I I V^21
5� EMERGENCY NOTIFICATION (IN EVENT OF FIRE, BURGLARY, ETC.)
E P HONE
)NAMIj �FIR-,T INITIAI
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T A M�, 7�FA C70.1 TELEPHONE
ELALST NAM E, FIRST INITIAL
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D � USE PERMIT
LAND USE I jN
A P I CA N T'S
Sj_
APPLICATION
for
The City of Edmonclt�'-, SEDE SEWER PERMT
EASEMENT No . ..........................................
NEW CONSTRUCTION REPAIRS C]
325-09290
Mrs. Ruth B. Henton
OVVNER.............................................................................................................. CONTRACTOR .................................................................................................. PERMIT No . ......................
ADDRESS ....... qq�h .... A.ven.u.e .... W ...................................... LEGAL DESCRIPTION: LOT No . .............................................. BLOCK No . ............................................
... .. ......... .. ..
NAMEOF ADDITION .........................................................................................................................................
Dye Tested On Sewer 1972
Approved:
DATE................................................ By ......................................................................