214 MAIN STJT-
CITY OF EDMONDS
COMMERCIAL
USINESS LICENSE APPLICATION
FEE: $125.00
TH CITY CLERK'S OFFICE, BUSINESS LICENSE DIVISION
191A AVFNLJF NORTH- EDMONDS. WA 98020 PHONE 425.775.2525
•
BuOding
•
Engineering
0
Fire
•
Planning
•
Police
OFFICE USE ONLY
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INSTRUCTIONS: Please complete the application in full and attach the required floor plan. Middle initial or name required of all parties concerned. ff no
middle name, please Indicate by writing NMN. Sign and return application with fee. Please advIs6 of any change In status. Now license required If
business changes location or ownership. Notification to City of Edmonds required If business closes. License expires December 318* each year. Renewal
must be submitted prior to January 316t to avoid late fees.
BUSINES . SNAME—MATMEW UL�101'-L D&A MAIM STU; C-1 INSLIANCAE
BUSINESSADDRESS Z1q MAIN ST-k-CET E'DAUNDS. A C)MV)
street Suite # City, State. Zip Code
MAILINGADDRESS 711114 fvlllltl� UPAONZIS WA %0Zb
Street or PO Box # Suite # CltyrState, Zip Code
-7 e�, LjLt Z 8 -11 S I Z 1--7
BUSINESS PHONEL A(, - WASTATETAXID#(U8Qj 3711 15 19
BUSINESS E-MAIL UL�JC41fiSOZAN&,o GMA
]L.COM BUSINESSWEBSITE
BUSINESS OWNER / MAIN CONTACT M AT114 W 9 (AUIA CA
Name Phone Number
PROPERTYOWNER 4-1 le- q -167
Name Phone Number
EMERGENCY NOTIFICATION (For Premise Access In
Last Name First Name MI Phone Number
(—I M N DANA (05 1
Edst Name First Name MI Phone Number
NATURE OF BUSINESS (Provide a Detailed Description of Business Activities, Products & Services):
INSUIZAN(-L SAIES
SPACE ALTERATIONS T . 0 BE MADE: YES_—NO_ZDESCRIPTION
PREVIOUS BUSINESS AT THIS ADDRESS MA -IN MUT 041"OCC
NUMBER OF EMPLOYEES SQUA7'0111�6FBIUSINESS SPACE (020
PROPOSED OPENING DATE: zc)
TYPE OF BUSINESS — PLEASE CHECK APPROPRIATE CA�&ORY.-
• CONSTRUCTION BUSINESS HOURS:
• FINANCE, INSURANCE, REAL ESTATE 10 10 se't
• LANDSCAPE, HORTICULTURAL DAYS OPEN:
• MANUFACTURING dWEDNESDAY
.o NON-PROFIT OSUNDAY
ci RETAIL &MONDAY d.THUIRSDAY
o SECONDHAND DEALER HVTUtSDA� WFIRIDAY
Tr SERVICES SATURDAY
a WHOLESALE
c3 OTHER
AMUSEMENT DEVICES ON PREMISES? YES— NO &"' IF YES, TOTAL NUMBER_LIQUOR SOLD ON PREMISES? YES— NO
GAMBLING? YES— NO 60e CIGARETTES SOLD ON PREMISES? YES__ NO '--I
FLAMMABLE OR HAZARDOUS MATERIALS USED OR STORED? YES NO &--"IF YES, PLEASE PROVIDE A LIST OF MATERIALS AND QUANTITIES:
PARKING SPACES ON SITE: TOTALSPACES 9 ACCESSIBLE SPACES FOR HANDICAP PARKING
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? YES V'
M,
SOLE PROPRIETORSHIP
NAME
LAST FIRST MIDDLE INITIAL
ADDRESS
STREET SUITEIAPT/UNIT # CITY/STATEIZIP CODE
HOME PHONE( I DRIVERS LICENSE OR ID # & STATE
DATE OF BIRTH CITYISTATE OF BIRTH ----QOUNTRY OF BIRTH
PARTNERSHIP - PARTNER I
NAME
LAST FIRST MIDDLE INITIAL
ADDRESS
STREET SUITE/APT/UNIT # CITY/STATEIZIP CODE
HOME PHONE( DRIVERS LICENSE OR ID # & STATE
DATE OF BIRTH CITY/STATE OF BIRTH COUNTRY OF BIRTH
PARTNERSHIP — PARTNER 2
NAME
LAST FIRST MIDDLE INITIAL
ADDRESS
STREET SUITE/APTIUNIT CITY/STATEIZIP CODE
HOME PHONE( RIVER'S LICENSE OR ID # & STATE
TE
CORPORATION1 LLC or PLLC
NAME OFCORPORATION, 1M NTTVALW
tALP-11CRI
UAL
—.FEDERALTAX D#
959 V� 7-9
CORP.ADDRESS 7,14 M A I N
STULT
LWoNM WA 9YOU)
(ILS ) 11+44H
Street
Suite, Apt. Unit#
City. dtate and Zip Code
Phone Number
CORPORATE OFFICERS:
Last Name
LA f4w
First Name
fA 071-wav
MI
6
Title Dateof Birth Driver's License or Other D# /State
0zj2jjI'qz-7 ULJA('Mm�opf ZKA
LOCAL CONTACT
Last Name
First Name
MI Title
Dateof Birth
LA ICN461SONI
/WA
z'5 ) -7 -1
Drives License or Other
ID# /State
Phone Number
CITY USE ONLY:
BUILDING DEPT. APPROVE DISAPPROVE DATE SIGNATURE—
OCCUPANTLOAD BUILDING PERMIT
OCCUPANCY GROUP
COMMENTS
ENGINEERING APPROVE DISAPPROVE DATE SIGNATURE
FIRE DEPT. APPROVE DISAPPROVE DATE SIGNATURE.
U.F
PLANNING DEPT. M APPROVE [--] DISAPPROVE DATE SIGNATURE
ZONING CODE CONDITIONAL USE PERMIT
COMMENTS
POLICE DEPT. APPROVE DISAPPROVE DATE SIGNATURE_
COMMENTS
Main Street Insurance
Floor Plan - 620 SQ FT
Back Ekit
FaxArea
Bathroom File Cabinents
Fax Area
Internet
Router
Hookup
Area
Desk I
Lavo�
OMOMOM Desk 3
Waitingarea C
Front Door
Width = 20Fr
JO,
Length = 3 1 FT
J�
41
�irving Brier, Edmonds, and
Terrace
www.FireDistrictl.org
12425 Meridian Ave S,
Everett, WA 98208
Phone (425) 551-1200
Fax (425) 551-1272 .
FIRE PREV ENTION
XINSPECTIO'N REPORT
EDMONDS
BRIER
13 MOUNTLAKE TERRACE
0 UNINCORPORATED
FREQUENCY STATION & SHIFT
LOCATION: 214 Main Street 98020 2015 17-D
BUSINESS NAME: SCHEDULED
Allstate Insurance PHONE: 425774448.8 DATED E o ec 5
MAILING
UFIR 0 591 202
ADDRESS: 214 Main Street, Edmonds, WA 98020
BUSI'N4E_SS OWNER: HOME PHONP a (p 9 ('S'- 0 "S'
EMERGENCY-1: (A L 9 1 C kf /"A 'r 7'/' ot-j HOME PHONE
: 4257744488 CURRENT
KEY ACCESS-2: HOME PHONE: CITy YES
BUSINESS
EMAIL: /bw4;-k) 1A LOXCH JQ(1jj-j97r_. COM
LICENSE E I F]
PERSON CONTACTED: INITIAL INSPECTION DATE
1�4 -,j
NAME OF INSPECTOR:
FIRE SYSTEMS: FE 12/13
ate Last Serviced7
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
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I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1st RE -INSPECTION
2nd RE -INSPECTION
EXTENSION
FINAL RE -INSPECTION
VIOLATIONS
DATE DUE:
DATE DUE:
GRANTEDTO:
DATE DUE:
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
1
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE: . I
DATE:
3
VIOLATIONS
V IOLATIONS'-.,. 't
PRE -CITATION
CITATION IS
L ER SENT
NUMBER:
4
2
6
2
6-
DATE:
CODE
SECTION:
5
7
RETURN RECEIPT
RECEIVED
DISPOSITION:
4
8
4
.8
DATE:
7
�,'LETTER NEEDED [] YES 0 NO
LETTER NEEDED [] YES NO
8
SNOI
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brving Brier, Edmonds, and
Mountlake Terrace
WOOIT wwwFireDistrictl.org
12425 Meridian Ave S
Everett, WA 98208
Phone (425) 551-1200
Fax (425) 551-1272
LOCATION: 214 Main Street 98020
BUSINESS NAME: AJIstate Insurance PHONE: 42577
MAILING
ADDRESS: 214 Main Street. Edmonds, WA 98020
1 j;3.0
BUSINESS OWNER:
Email:
EMERGENCY-1:
McSinnes, Michael
KEY ACCESS-2:
EMAIL:
PERSON CONTACTED:
r
Z2e� ZL
NAME OF INSPECTOR:
FIRE SYSTEMS:
FE �ZZ
HOME PHONE
FIRE PREVENTION
INSPECT16N REPORT
I�EDMONDS
0 BRIER
El MOUNTLAKE TERRACE
[I UNINCORPORATED
FREQUENCY STAIION & SHIF_*1)
W' Year 13 17-B
SCHEDULED Dec 2013
DATE DUE
LIFIR � 591
HOME PHONE: 4257744488' CURRENT
HOME PHONE: CITY YES NO
BUSINESS
LICENSE
INITIAL INSPECTION DATE
,�2111 :y
HAZARDS F LIND AND LOCATIONS / COMMUNICATIONS
AAj&AAL_. JAJI�26�;�plJ
2
2
3
4
r\
5
3
4
5
6
6
7
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1st RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTEDTO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
1
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
1 5
VIOLATIONS
1 5
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2
6
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED
6
4
8
4
8
DATE:
DISPOSITION:
7
LETTER NEEDED 0 YES NO
LETTER NEEDED C] YES El NO
FIRE DEPARTMENT COPY
CITY OF EDMONDS
121 5TH AVENUE N. - EDMONDS, WASHINGTON 98020 - (425) T71-0215
FIRE DEPARTMENT
LOCATION: 214 Main. Street
BUSINESS NAME: Alistate insurance
MAILING 214 Main St
FIRE PREVENTION
SAFETY SURVEY
PHONE: 4257744488
ADDRESS: Edmonds 98020
BUSINESS OWNER: McGinnes, Michael HOME PHONE: 4257744488
EMERGENCY-1: HOME PHONE: 425i780255
KEY ACCESS-2: Fredrickson, Roy HOME PHONE:
FREQUENCY
STATION & SHIFT
730
17 C
SCHEDULED
1z011110
DATE DUE 0'
LIFIR o. 591
1202
A,CTIVE
INITIAL INSPECTION DATE
PERSON CONTACTED: PAC -A/ .
NAME OF INSPECTOR: tJ Tn-2-
FIRE FE
SYSTEMS:
ANNUAL
HAZARDS FOUND AND LOCATIONS C MMUNICATIONS
Co i
be tkdoe exl e o w w1a
ENTER CODE ONLY ONCE 11�
Vlo N CODE
2
2
3
3
4
4*
5
5
6
6
7
7
8
8
'Ist RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTED TO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
I
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
3
VIOLATIONS
1 5
VIOLATIONS
5
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2
6
2
6
DATE:
CODE
SECTION:
5
3
7
7
RETURN RECEIPT
1 RECEIVED
6
14
18
4
18
DATE:
DISPOSITION:
8
LETTER NEEDED [] YES NO
LETTER NEEDED E] YES NO
1
FIRE DEPARTMENT COPY
MEMORANDUM . pt, 6
DATE el
I
REPORTED BY&,�A-((- tVfLj-4jA1&�tZ OF
SUBJECT 0 PC I -Al
ADDRESS:
CONCERNS/
HAZARDS: 244 /L St C-A
PSA-Pc4
FoLLow-up:
3/ � /,?? & 0 —( A- C4�� r,72160
J—d�4w (00
O&C(fie- k/fw /Ifst ' CA,
7-6 COMP- bas"A / C?- - Jj' .
SIGNED- :�
SIGNED
City of Edmonds Sb Office of Fire Prevention