22019 HIGHWAY 99.PDF11586
22019 HIGHWAY 99
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TAX ACCOUNT/PARCEL
BUILDING PERMIT (NEW STRUCTURE):
COVENANTS (RECORDED) FOR:
CRITICAL AREAS:
DISCRETIONARY PERMIT
DRAINAGE PLAN DATED:
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED
PERMITS
PLANNING DATA CHECKLIST DATED:
SCALED PLOT PLAN DATED:
I
DETERMINATION: F� Conditional Waiver n Study Required E] Waiver
SEWER LID FEE $: LID #:
SHORT PLAT FILE: LOT: BLOCK:
SIDE SEWER AS BUILT DATED:—
gj Ito
SIDE SEWER PERMIT(S) #: It c�
GEOTECH REPORT DATED:
STREET USE / ENCROACHMENT PERMIT #:
WATER METER TAP CARD DA
OTHER: I OT-1 q — m q
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CITY OF EDMONDS
121 5TH AVENUE NORTH - EDMONDS,WA 98020
PHONE: (425) 771-0220 - FAX: (425) 771-0221
Friday, October 24,2008
This Application has been accepted by the City of Edmonds for review. More infon-nation and changes niay be
required during this process. The review target date is: Friday, October 31, 2008
Your City Contact is: LINDA THOMQUIST STREET HLE
Application Nurnber: BLD20080890
Project Address: 22019 HIGHWAY 99, EDMONDS
PROPmryOWNER APPLICANT
OLYMPIC SPINE TUBE ART DISPLAYS, INC.
1000 SECOND AVE STE3330 1705 4TH AVE S.
SEATTIA WA 98104 SEATTLE, WA 98134
suuff HLE 206-223-"22
Work DescriDdon:
INSTALL NEWSIGN CABINET ON EXISTING POLE SIGN.
Outs tanding hems at Time of Submittal:
C WLEDGE a
ATIHAVER WINISAPPLI A RECT
EREB n 6WA" li'l- E�W� 1�01 a
AND THAT I AM INE PROPERTY OWNER, OR TNE DULY AUTIJORIZED AGENT OF THE PROPERTY OWNERTO
641 SUBMITA BUILDING PERMIT APPLICATION TO THE CITY.
S IG NATURE (0 W NER 0 R AG 11"
PRINTNAME
DATESIGNED
STREET RLE
To view up to date information about your application please visit the City ofEdmonds Development Services
website at http://www.ci.ednwnds.wa.us.
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WA UT%, WSJ.:-.
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Brief Description: NEW S I (,-tt,3 64S42 t's 7
S,
SiteAddress: 17,2.a (9. F�V-kC Suite #
Sno County Tax Account Parcel #: 0 A2_61 oo 3, 01 q 0 C>
Businessfrenant Name (if applicable):
v
Mailing Address:
City: S� tz_
Phone: (_)
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.CONTRACTMR: QSaiiffifi 'IEL-6whdr. eriName) silk A wiz
7p!;�Ch &
Mailing Addressj
City: State* Zip:
Phone: 1-7-77 FAX: E-Mail:
"State License Number: Exp: Date: 0&0% Business License No:
a 'W+n6r, ame-As Contrii6tor.... 00tH
APPLICARTICONTAPT! - >6S.-
Fill out the following information if "Other".
Name & Mailing Address:
City: State: Zip:
Phone: FAX: E-Mail:
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CITY OF EDMONDS
121 5TH AVENUE NORTH - EDMONDS, WA 98020 - (425) 771-0220 - FAX (425) 771-0221
Website: ww6edmondsma.us
DEVELOPMENT SERVICES DEPARTMENT
o", Planning - Building - Engineering
September 2nd, 2009
Shawn Bowen
Tube Art
1705 4"' Ave S
Seattle, WA 98134
RE: Plan Check # 2008-0890
Project: Sign
Project Address: 22019 HWY 99 / Olympic Spine
Dear Shawn Bowen,
GARY HAAKENSON
MAYOR
Please respond to the enclosed comments from Kernen Lien, Planning Department
regarding the sign application. The City cannot continue to process your application
until you fully respond to the Plan Review Comments.
The application will expire on 10/23/2009. Due to the present economic situation, the
City Council has approved a temporary ordinance which would allow an extension of
applications for an additional year. To extend the subject permit application you must
submit a request in writing to the Building Official.
Please be advised, once a permit application expires, the application materials and plans
on file with the City will be destroyed within ten working days. Also, if you wish to
pursue the project in the future a new permit application and new fees will be required.
If you wish to withdraw the application and not continue with the project please send a
statement wishing to withdraw the permit application. If you have any questions please
contact a permit coordinator.
Sincerely;
z
Linda Thomquist
Permit Specialist
City of Edmonds Building Dept.
425-771-0220 ext. 1336
Cc: File
L\Temp\DST's\M aster Letters\Pls Respond
Incorporated August 11, 1890
Sister City - Hekinan, Japan
-111,c. 18 C) 1)
CITY OF EDMONDS GARY HAAKENSON
MAYOR
121 5TH AVENUE NORTH - EDMONDS, WA 98020 - (425) 771-0220 - FAX (425) 771-0221
Website: www.ci.edmondsma.us
DEVELOPMENT SERVICES DEPARTMENT
Planning - Building - Engineering
March 9, 2009
Shawn Bowen
Tube Art
17054 1h Ave S
Seattle, WA 98134
RE: Plan Check # 2008-0890
Project: Sign
Project Address: 22019 HWY 99 / Olympic Spine
Dear Shawn Bowen,
Please respond to the enclosed comments from Kernen Lien, Planning Department
regarding the sign application. The City cannot continue to process your application
until you fully respond to the Plan Review Comments. If you have any questions please
don't hesitate to call. Thank you.
Sincerely;
Linda Thomquist
Permit Specialist
City of Edmonds / Building Dept.
425-771-0220 ext. 1336
Cc: File
L\Ternp\DST'sWaster LettersTIs Respond
Incorporated August 11, 1890
Sister City - Hekinan, Japan
0
TUBE ART GROUP
September 8, 2009
ATTN: Linda Thomquist
City of Edmonds
121 5'h Ave. N.
Edmonds, WA 98020
Re: Plan Ck# 2008 0890
SEP 0 2009
BUILDING DEPARTMENT
CITY OF EDMONDS
Please use this letter as requests to withdraw the current sign permit application as the job has
been canceled.
Please feel free to call me at (206) 223-1122 if you should have any questions.
Sincerely,
TUBE ART DISPLAYS, I`NC.
Shawn TBowe
Permit Acquisition
SEATTLE OFFICE 1705 4th Ave South, Seattle, WA 98134-1514 1 206.223.1122 800.562.2854 1 Fa. 206.223.1123 1 tubeartgroup.com
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CITY OF EDMONDS
121 5TH AVENUE NORTH - EDMONDS,WA 98020
PHONE: (425) 771-0220 - FAX: (425) 771-0221
Friday, May 15, 2009
This Application has been accepted by the City of Edmonds for review. More information and changes may be
required during this process. The review target date is: kliz-1o.1
Your City Contact is: Waso"
Application Number: BLD20090297 S I HEET VILE
Project Address: 22019 99 HWY #A, EDMONDS
PROPEWIN OWN Ell APPLICANT
OLYMPIC SPINE & SPORTS GEORGE HILT
1000 SECOND AVE STE3330
SEATTLE, WA 98104- -
( ) - Ext. i206) 422-3735 E-A.
Work Description:
INTERIOR REmODEL STREET FILE
Outstanding hems at Time of Subn-dttal:
CONTRA CTOR'S WRITTEN BID AND CONTRACTORS
CORR
KN PAD
A C 90-W L EDG T I HAVE READ THIS AP
I HEREBY' PLICAOONIMA'T VEOR 0 9GIV, WIST
AND TH E PRO PERTY OWNER, 0 R THE DULY AUTHO RIZED AGENT 0 F THE PRO PERTY OWNER TO
SUBMIT A BUILDING PERM7 APPLICATIO N TO THE C ITY.
6-,
0 R AGENT) PRINTN
To viewup to date information about your application please visit the City ofEdmonds Development Services
website at http://www.ci.ednwnds.wa.us.
CITY OF EDMOND&
121 5TH AVENUE NORTH - EDMONDS,WA 98020
PHONE: (425) 771-0220 - FAX: (425) 771-0221
Friday, May 15, 2009
This Application has been accepted by the City of Edmonds for review. More information and changes may be
required during this process. The review target date is: DCA
Your City Contact is: :fli "4—
Appfication Number: BLD20090298
Project Address: 22019 99 HWY #13, EDMONDS
PROPLRINOWNER APPLICANT
US CREDIT ADVISORY CROUP GEORCEFULT
1000 SECOND AVE STE3330
SEATTLE, WA 98104- 1 -
( ) - EX. (206) 422-3735 FA.
Work Description:
INTERIOR REMODEL
Outstancling henis at Time of Submittal:
CONTRA CTOR'S WRITTEN BID AND CONTRACTORS 67���
AfI PREB
E I V A C I#W L)EDIE THU I P TIO N 11HA TNEINFORMATION GIVEN IS CORRECT
ANDIHA5TIAM THEPROPERTY OWNER, OR IMEDULY AUTHORIZED AGENTOFTHEPROPER-IY OWNER TO
SUBMITA BUILDING PERMIT APPLICATION TO TFIECITY. I
WNER OR AGENT) PRINTNANK YATIE S
To view up to date information aboutyour application please visit the City ofEdmonds Development Services
website at hilp://www.ci.ednwnds.wa.us.
City of Edmonds
Permit Application Form
Form A
4A7 X�
1 0&dt n V1-4-k
Permit Application for: E] New SinEfle-f , A mily El. New: Com/Apt Addition
Interior Remodel 11 GA.r.-a0,d1.CArport:1. E] Repair,
Sign
[-I Fence EJ.Gtad1h Vds� ED'Storage/Shed
911, c
�Tenant lmorovemenVC-hange:-,�.t':.Us''e� E] Fire Sy'stem (Specify)
Rockery/Retaining Wall
F1 Other (Specify) DATE: s//S/,P
Brief Description:
6; VM 4 r -e aL
A -
Site Address: 2- 0 q 7tV4 Ax 14 tot :
Sno County Tax Account Parcel #:
Business/Tenant Name (if applift
Mailing Address:
City: 040AF-114,21 1 a StatNWI V I I ILA 17
P
Phone: (2-06' )A-/-3 FAX: "W-ail:InDrWen
(25
CONTRACTOR: DSame as Property -Owner oafti
Mailing )�ddress: '702- -57?w7w lZou-r-p 9 -sg-
city: State: WA.
Is
Phone: (2-OLO ) '313 — 08YZI FAX: GO ) &bff-.1q4? E-Mail: 2- e
-YA
State License Number: —Xo K47tFd-8 9 7.2- C Exp: Date:7 //A20// City Business License No:
APPLICANT/C ' ONTACT: DSame as Property Owner Same as Contractor -00ther
Fill out the following information if "Other".
Name & Mailing Address: 6790�tj 0-
City
State: Zip:
Phone: (Z-06 ) qzr-- 3;7,51— FAX: (_)
E-Mail:
L:kTEMP\BUILDING\WEBchecklists\SFR.COMM.APP.doc5/24/2007 1
I/ DETAILED SCOPE OF WORK
Please provide a complete detailed written scope of work for the proposed
project.
Additions (additional square footage): Specify room use, floor level and square footage and
direction if applicable (i.e. 545 square foot master bed room/bath room addition on the second floor
with 140 square foot deck and 245 square foot kitchen addition on the main floor at south side of
house).
Remodels (interior renovations): Specify room uses and floor levels (i.e. combine bedrooms 1 and
2 on the main floor to create new master bed room/bath room; replace dining room sliding glass door
with new French doors, reconfigure kitchen with new island prep counter and install new gas fireplace
in the living room).
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8111, AVG 20%
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Jorgensen Custom Builders, Inc.
425.481.1776 Mobil 206.422-3735 Fax 360.668.1449
13702 State Rte 9 SE — Snohomish, WA 98296 email: georgehilt@msn.com Lic. #JORGECB972CR
August 12, 2009
City of Edmonds
121 — 5" Ave North
Edmonds, WA. 98020
RE: Plan Check BLD2009-0297 / Interior Remodel for Olympic Spine & Sports
and US Advisory Group
Theresa Umbaugh,
I regret to inform you that this project is no longer a viable option for a couple of
reasons. The 20% accessibility upgrades along with the fact that this building is
scheduled for demolition in the next couple of years has cause our clients to reconsider
their options.
Please remit to our office, any deposits that were to be applied towards permits.
Thank you for your patience..
Sincerity,
George Hilt Prg. Mgr
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CITY OF EDMONDS
121 5TH AVENUE NORTH - EDMONDS, WA 98020 - (425) 771-0220 - FAX (425) 771-0221
Website- www ci edmonds wa us
DEVELOPMENT SERVICES DEPARTMENT
Planning - Building - Engineering
August 17, 2009
Jorgensen Custom Builders
George Hilt
13702 State Route 9 SE
Snohomish, WA 98296
Re: Permit Application: BLD2009-0297 & 298 / Interior Remodel for
Olympic Spine & Sports and US Advisory Group
Site Address: 22019 Highway 99 Suites A and B
Withdraw Date: letter received from Applicant 8/17/09
.Dear George Hilt;
GARY HAAKENSON
MAYOR
The purpose of this letter is to inform you that the above referenced pen -nit application has been
withdrawn. The plan review fees paid are non-refundable as the fees pay for City staff time in
review of the project.
If you wish to have your application materials and plans returned please immediately inform our
offices. The application materials and plans will be destroyed 10 days from the date of this letter
on 8/27/09. If you decided to pursue this permit application 'in the future you shall be
required to submit a complete application and pay new plan review and permit fees.
I
If you have any questions feel free to contact our office at 425-771-0220.
Sin rel
Th res baugh
Senior Permit Coordinator
Incorporated August 11, 1890
Sister City - Hekinan, Japan
00
C)
Ln
CITY of E D N D S DE SEWER PEUIT
For Inspection Call 771-3202 E T FIL PERMIT NO.
Address of Construction: 0 t4l y
J
Property Legal Description (Include all easements):
Owner and/or Builder: 14. 0 IF u k A
Contractor & License No: pts7,5 1641,-�616 Pl&h),61411 V �fl&'gp R1155 _T CS / )6 /'/)1
Single Family Residence VIA =181ALLINGER
ST CIO
Multi -Family (No. of Units LIFT STA�TION
Commercial (No. of fixture Units
Invasion into City Right -of -Way: No k"' Yes (If Yes, Right -of -Way -
Construction Permit required. Call One -Call -Center (1-800-424-5555) before any
excavation.)
Cross other Private Property: No po' Yes (If Yes, easement required,
attach legal description and county easement number.)
PLEASE READ THE ITEMS LISTIED ON THE BACK
RECEIVED
/ 6 /11 lrq
I certify�that I have read and shall comply OCT 0 3 1989 Dato'
with the items listed on the back.
PUBLIC WORKS
Permit Fee: ,30 - C-55 Issued By: S.
Trunk Charge: Date Issued: /0 - �2
Assessment Fee: Receipt No.: 60
Z-/,o
Partial Inspection:
Comments Date Initial
Final Inspection Approved:
Date Initial
Rejected:
Reason Initial
** PERMIT MUST BE POSTED ON JOB SITE **
Wh-ite Copy - File Green Copy - Inspector Buff Copy - Applicant
L
�The City of Edmonds Side Sewer Drawing EASEMENT NO - --------------------------------------------
NEW CONSTRUCTION REPAIRS 0 LID NO - ------------------ IASMT. NO - ------------------
rj-u
OWNER ------------------------------------------------------------------------------------------------ CONTRACTOR ------------------------------------------------------------------------------------ PERMIT NODO-"'--7f�
JOB ADDRESS --- - ---- ----- �-1 ---------------------- LEGAL DESCRIPTION: LOT NO. - ------- ---------------------------- BLOCK NO - ------------------------------------
------------------------- I ----------------------------------------------------------------------------------------------------------------------------------------
NAMEOF ADDITION ----------------------------------------------------------- -----------------------------------------------------------
IVIA BALLINGER
LIFT STATION I
Ise,
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oo,
eto � 0-10 c 7- —L 0
119* C::t t494.- a.T -,6
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,31 1
f 0 Approved -
PWW-0001 -11/75 (REV. 11/78)
LA, C) DATE-� - — -------------- --------------------- By ------------------------------------------------------------
orlt
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CITY of EDIANDS E ",S EN E R- E'R' M I T
-T RE 'PERMIT.NO.
for Inspection Call 771-3202 STREE
z Z011
OU
Address of Construction: 7-j-EE� "'." I \' \L�'� -
Property Legal Description (.Include all easements):
Owner and/or
Builder: r)l
Contractor &
License No:
Single Family Residence
Mul ti-Family
Commercial
[TIJABATLaLIN R
L FTT Ta
(No. of fixture Units
Invasion into City Right -of -Way: No Yes (If Yes, Right -of -Way
Construction Permit required. Call One -Call -Center (1-800-424-5555) before any
t4
excava ion.)
Cross other Private Property: No Yes (If Yes, easement required,
attach legal description and county easement number.)
(No. of Units
"tPLE AD THE ITEMS LIO-HED ON THE BACK
RECEIVED
%T—c'-rttf� that I have reacr-and shall comF,—y MAR 0 2 1990
c
<t�hr�the items listed on the back. PUBLIC WORKS
�Issued By:
Permit Fee:
Trunk Charge: A0 -60W/w C Date Issued: b
Assessment Fee: - &/�> Receipt No.: Id 2
Partial Inspection:
Date
Comments Date Initial
Final Inspection Approved:
Date Initial
Rejected: 12h I ks a el*-v M 4it w*s 4 vJ0 41-1'49
U'R6ason I Date Initi
** PERMIT MUST BE POSTED ON JOB SITE **
Wh-ite Copy - File Green Copy - Inspector Buff Copy - Applicant
The City of Edmonds Side Sewer Drawing EASEMENT NO - -------------------------- ------------- I )f I
NEW CONSTRUCTION E] REPAIRS [�e LID NO - ------------------ - ASMT. NO - ------------------ -
)w -
4-k
OWNER------------------------------------------------------------------------------ ................. CONTRACTOR --------------------------------------------------------- ...................... PERMIT NO. 0.3 --- L
JOB ADDRESS --- Zaavq --- nAAW� --- �_cl ------ ------------------- LEGAL DESCRIPTION: LOT NO - -------------------------------------- BLOCK NO - ------------------------------------
--------------------- --------------------------------------------------------------------------------------------------------------------------------------------
NAME OF ADDITION ------------------------------------------------------------------
----------------- J77ttr-r BgEE]r�NYGER-1
LjF-i- S-1-ATION
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PWW-0001-1 1/75 (REVA 1/78)
Ll
Approved:
DATE................................ By ............................................................
To: City of Edmonds
From: Eric Behla
Re: Building permits
Date: March 12, 2002
RECEIvE:Ej
M A, "R II ZW
DEVELOPMENT �EWCES CTR
r)
CITY OF E. MONDS
This memorandum is to put forth the wishes of the owners of the property at the comer of
220" and Highway 99, Edmonds, Washington. Please see attached site plan for property
location information. Currently the buildings and addresses on said property are:
Schucks Auto Supply, 22001 Highway 99;
Funtasia Family Fun Park, 7212 220th St. S.W.;
Seattle Skating Club (Edmonds Bingo & Pulltabs), 22111 Highway 99;
4RUMEMP S1eihk,-e*(fiM-"UsMd6 ffie&bdiIdiffg-,. �durfe—nt ISF_�p i4lly-
�ccp&d-byL. o
f �C*'oonsul�tants�Nort��h—we-g-t�)-Ff,2,f2--OfWI4iF;gllriVa—y,99'
Auto Consultants Northwest (metal warehouse building), 22001 -B Highway 99.
In regards to any permit issued by the City of Edmonds that pertains to any building or
remodel activity, which may from time to time be planned on the above -mentioned
addresses/property, we would like to make known the following:
In an effort to preclude any building or remodel activity inadvertently commencing on
said property without our advance knowledge and approval of such activity, we, the
owners, hereby request that any permitting documentation issued by the City of Edmonds
first receive owner's (or legally appointed representative) 'approval and authorized
signature. And ftirther, that the applicant for permit first present to City of Edmonds a
written approval, signed by the owner or legally designated representative, for proposed
building or remodel activity.
Ltt�c . _DAL,
Eric J. Behla, Property manager
(as legally appointed representative for
Herman C. Behla and Mary J. Behla, owners)
Eric Behla
P.O. Box 503
Edmonds, WA 98020
Ph. (425) 672-3965
03/23/99 10: 56 FAX 425 455 1626 RODGERS/DEUTSCH 002/003
EXHIBIT' ly B
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Aluminum face with mountain neon gole
And sold bar neon in center
Raised gold upper letters and
Raised silver lower letters with indirect lighting fluorescent
sign shows hinged face for service total devth 7"
D E'. S I G N E. 'D S I G S
(425) 774-1964
Fax (425) 778- 1 M
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6925 2.16th St SW, Suite j
Lynnwood, WA 98036
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PERMIT COUNTER
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PERMIT NUMBER
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6925 216th St. S.W. Suite j
Lynnwood, WA 98036
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BUSIrfS LICENSE APPLICATION
CITY OF EDMONDS
7 250 5TH AVENUE NORTH
,�MOVS, WASH. 98020
1 -EdIfPH - E (206) 775-2525
�E
T
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el INSTRUCTIONS
I � PRINT APPLICABLE LICENSE CLASS, FE E 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 INFORMATION 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
TO APPEAR FOR APPLICATION -REVIEW.
ANNUAL FEES
TYPE BUS. CLASS
FEE
PENALTY
HOME A
�10.00
S 5.00
SMALL B
15.00
7.50
*GENERAL C
50.00
25.00
*OVER 10 EMPLOYEES. OR EMPL WORK
OVER 120 MAN -MONTHS PER YEAR.
CLASS L, FEE PAID PENALTY PAID
LICENSE RENEWAL Q
T.
REVIEW BELOW INFORMATION. PRINT CHANGES AT RIGH L2
2. APPLICANT
NAME SOCIAL SECURITY NO.
DATE OF BIRTH PLACE OF BIRTH
HOME ADDRESS
3. BUSINESS IDENTIFICATION
BUSINESS NAME
NATURE OF BUSINESS BUSINE SS PHONE
WASH. STATE TAX NR. EMPLOYEES I ORGAN. JOCCUPANCY
TYPE ORGANIZATION
IF BUSINESS IS:
TYPE
CAPACITY
HOTEL/MOTEL
L
NR OF ROOMS/UNITS
C CORPORATION
. .
APT.BLDG.
A
NR OR APTS
L LTD. PART
OFFICE BLDG.
0
NR OF OFFICES
P PARTNERSHIP
RESTAURANT
R
NR OF SEATS
S SOLE OWNER
HOSPJNURS. HOME
H
NR OF BEDS
SCHOOL'
S
NR OF STUDENTS
4. BUSINESS ADDRESSES
BUSINESS ADDRESS
LICENSE MAILING ADDRESS
5. EMERGENCY NOTIFICATION
NAME
AREA
TELEPHONE
(1)
(2)
OFFICIAL USE ONLY
U.F.I.R. CODE
BLDG.
PERMIT
OCC7
C.U. PERMIT
LAND
=
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STAFF ACTION
RE�VERSE APPL. NO.: d.-2
SIDE DATE:
�APPLICATEION FOR:
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BUS. RENE YEAR
r, I CLASS I LEIR I LIC. EFFEC. DATE
LA NEW BU
LB RENEWA�
LC CHANGi
LD DELETE
REASG. LIC. NO. I SV�
RECEIPT NO. DATE PAID
RINT 'X*
15 T n, 7\ IN SPEC. 80
FOR ISSUE 0
FEE PAID PENALTY PAID C 0 R R E C T E I
10 711 - LICENSE Wilt
C I 'LC' ACTION.
LICENSE APPLICATION AND CHANGES
PLEASE PRINT CLEARLY
1112.
APPLICANT
LAST NAME, FIRST INITIAL CIAL SECURITY NUMBER
. IL"
J_
DATE OF BIRTH PLACE OF BIRTH
MO. I DAY IYEARI CITY STAI F
HOME ADDRESS
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3. BUSINESS IDENTIFICATION
BUSINESS NAME (FULL)
A I- L'i-01 L I
NATURE OF BUSINESS (DRUG STORE, CPA, ETC) BUSINESS PHONE
I LL111
TICIPATED TYPE OF OCCUPANCY
(REGISTRVION NR.EMPLOYEE S ORGAN. TYPE CAPACITY
WASH. STATE AX )NR. AN M T
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4. BUSI.NESS-Ag
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CITY
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5. EMERGENCY NOTIFICATION (IN EVENT OF FIRE,
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ETC.)
LAST NAME, FIRST INITIAL
AREA CODE
TELEPHONE
AREA CODE
LAST NAME, FIRST INITIAL
TELEPHONE
(2)
I I I iNi I I I I I I
Jai UAIL6
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COND. USE PERMIT LAND USE ZONING
I
CITY CLERK'S APPLICANT'S
iIGNATURE SIGNATURE
APPROVED DISAPPROVED DATE BUS. TITLE
CC-1 (10/76) 17 7-7- 7 1 j IT 1 rJ T 0 c T, r v r i <
DATE '- � I/(-
BUSIOSS LICENSE APPLICATION
P17
CITY OF EDMONDS
250 5TH AVENUE NORTH
EDMONDS, WASH. 98020 '10
lj iTEIEPHONE (206) 775-2525 150,
T E E If iLt:
INSTRUCTIONS
1. PRINT APPLICABLE LICENSE CLASS, FEE AND PENALTY PAID
IN.ANNUAL FEE BOX AT RIGHT. PENALTY DUE ON RENEWALS
RECEIVED BY CITY CLERK AFTER FEBRUARY 15.
2. NEW BUSINESS: 'COMPLETE ALL LICENSE� APPLICATION BOXES.
LIC. RENEWAL: REVIEW LICENSE INFORMATION 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
11 TO APPEAR FOR APPLICATION REVIEW.
HOME ADDRESS
e'-ANNUAL FEES
TYPE BUS. CLASS FEE PENALTY
HOME A $10.00 $ 500
SMALL B 15.00 7.50
*GENERAL C 50.00 25,00
10 EMPLOYEES, OR EMPL WORK
OVER 120 MAN -MONTHS PER YEAR.
CLASS I FEE PAID PENALTY PAID
C oo
U , I- Ij
S ,TION, PRINT CHANGES . A'T'�Rl G H ��T.,
E RENEWAL
PLACE OF BIRTH
RITY NO.
3. BUSINESS IDENTIFICATION
BUSINESS NAME
NATURE OF BUSINESS BU SINESS PHONE
WASH. STATE TAX NR. EMPLOYEES OIR GAN. 7�� Y
TYPE ORGANIZATION
IF BUSINESS IS:
TYPE
CAPACITY
C
0
C CORPORATION
HOTEL/MOTEL
L ,
NR OF ROOMS/UNITS
APT.BLDG.
A
NR OR APTS
D
L LTD. PART
OFFICE BLDG.
0
NR CIF OFFICES
E
P PARTNERSHIP
RESTAURANT
R
NR OF SEATS
s
S SOLE OWNER
HOSPJNURS. HOME
H
NR OF BEDS
SCHOOL
S
NR OF STUDENTS
4. BUSINESS ADDRESSES
I BUSINESS ADDRESS
LICENSE MAILING ADDRESS
5. EMERGENCY NOTIFICATION
NAME
AREA
TELEPHONE
(2)
OFFICIAL USE ONLY
U.F.I.R. CODE
BL DG. PERMIT
OCCUPI
C.U. P - ERMIT
LAN . D U7��_
E STAFF ACTION,-,:,',
REVERSE APPL. NO.:
SI
SIDE r,l r
DATE:-
WL IC ATION FOR:
NEI LIC. LICENSE
B US 11 RENEW YEAR
LlCENSE NU::I:j [nAC-TIO LA NEW BU
LB RENEWA'
I I LC CHANGE
LD DELETI
CLASSI YEA,�R LIC. EFFEC. DATE I R.EASG. LIC. NO. I SP!
RECEIPT NO DATE PAID
PRINT X
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FO
FEE PAID R ISSUE OF
PENALTY PAID I C 0 R R E C T E I,
LICENSE WIT�-
'LC' ACTION
LICENSE APPLICATION ANbCHANGES
PLEASE PRINT CLEARLY
2 APPLICAN
LAST NAME, FIRST INITIAL SOCIAL SECURITY NUMBER
- I I I ��j )L" I /� /-,I "
_�j I L , i ol (/'10
T, L
Ej
DATE OF BIRTH PLACE OF BIRTH
kR F7TA _TF�.
ICITY
LI I I I I I I I I I
HOME ADDRESS
BLDG. NUMBER I
F�FE _T APT. -NO.
CIT I Y _nTE ZIP CODE
TAJ
3. BUSINESS IDENTIFICATION
BUSINESS NAME (FULL)
CIL101 lf4 Aili I tOf &ii J�ii I QA iAii Kj I Ojf� I
r-NATYRE OF BUSINESS (DR� STORE, CPA, ETC) S PHONE
7, 7 I.sl k, q,
WASH. STATE TAX NR. ANTICIPATED TYPE OF OCCUPANCY
(REGISTRATION) NR. EMPLOYEES tORGAN. TY�PE CAPACITY
j -5 C_ ? E
0 c 0
ENTER APPLICABLE TYPES AND CAPACITY t
4. B U �!NESS-AlDIIYR
.NU 8 STREEI
117 14.11
BLDG. NUMBER ST EET
AP
rT. NO.
CITY ISTATE I I ZIP CODE
F-101ml J-1 L��,_& aLg toj-� ID I
EMERGENCY NOTIFICATION (IN EVENT OF FIRE, BURGLARY. ETC�)
LAST NAME. FIRST INITIAL !. � I " . AREA CODE TELEPHONE_�
0) LI-1 I I I L I L I L A I rN S4 I ('I 04A—=Vi� Q10 I(p '11-119 UZ 1 31,
(2) LAST NAME, FIRST INITIAL AREA CODE TELEPHONE
AILj�_Il�jAiNI0jf_IQI lMlftpkr(,-, 5_tj� LL4 'A�C,
L
5S OFFICIAL USE ONLY
U.F.I.R. I PRIM.' UNITS BUS. BLDG. PERMIT OCCUP. GRP.
I I I 1 11 1 1 1 1 1 R -2L
COND. USE PERMI ZON I N�� -I
-,-i L,-j E-1 _L_� (.0
CITY CLERK'S APPLICANT'S
SIGNATURE TU
SIGNATURE
APPROVED DISAPPROVED DATE US TIT LE
BUS. =TI T L E
FORM CCA (10/76)
DATE I - &
Id
- ---- - ---- -
'77
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