221 JAMES ST STE 200jr
'T-
CP -'OF-EDMONDS
BUSHESS LPCENSE APPLICATPON - COMMER06AL
AfT 10 �.W FEE: $125.00
CITY CLERKS OFFICE, BUSINESS LICENSE DIVISION
'I �Zj'OJTH AVENUE NORTH, EDMONDS, WA 98020 PHONE 425.775.2525
•
Building
•
Engineering
r�
Fire
li
Planning
0
Police
7'1'774'_ OFFICE USE ONLY
BL#
)mer #
�1�
SIC
1'72hilE,01�
I Year
Class
I
Sector
I.2-01'Ir-1041
I Date Paid
I TR#
Mailed
Deleted
I
INSTRUCTIONS: Please complete the application in full and attach the required floor plan. Middle initial or name required of all parties concerned. If no
middle name, please indicate by writing NMN. Sign and return application with fee. Please advise of any change in status. Now license required if
business changes location or ownership. Notification to City of Edmonds required if business closes. License exDIres December 31't each vear. Renewal
must be a
BUSINESS
BUSINESS
;��,0�2
MAILING ADDRESS j
BUSINESS PHONEL_
BUSINESS E-MAIL.- 00o
BUSINESS OWNER / MAIN CONTACT
Last
IRV-(4 N RA �_F I 4�c�n=L 'Wr
1,
Street or PO Box # City, State. Zip Code
f _�I 'r%
TV WA STATE TAX ID # (UBI)
trh H�Zll 4 [ 0 1 � I � I I �
USINESS WESSITE_�'.
NOTIFICATION (Fqr Premise Access in
Last Narhe - V 'First Name
NATURE OF BUSINESS (Provide a Detailed Description of Business
ALTERA, TIONS TO
Products &
NUMBER OF EMPLOYEES !:4 SQUARE FOOTAGE OF B
TYPE OF BUSINESS - PLEASE CHECK APPROPRIATE CATEGORY:
• CONSTRUCTION
• FINANCE, INSURANCE. REAL ESTATE
u LANDSCAPE, HORTICULTURAL
n MANUFACTURING
0 NON-PROFIT
RETAIL
SECONDHAND DEALER
-9- SERVICES
• WHOLESALE
• OTHER
AMUSEMENT DEVICES 00 PREMISES? YES— NO.Y_IF YES, TOTAL
GAMBLING? YES— NOK7. CIGARETTES SOLD ON PREMISES? YES
,Phone
9
PROPOSED OPENING DATE:.___..jjj?6j Z4-, Z
T
BUSINESS HOURS: n_10 L ae- it. j --,I-
DAYS OPEN;
o SUNDAY �O'WEDNtSV�
,4'MONDAY '7-;CTHURSDAY
)(TUE96AY XFRIDAY
YSATURDAY
SOLD ON PREMISES? YES NOX—
F NRABLE OR HAZARDO S MATERIALS USED OR STORED? YES-,S NO IF YES. PLEASE PR
OVIDE A LIST OF MATERIALS AND QUANTITIES:
PARKING SPACES ON SITE: TOTALSPACEt I U ACCESSIBLE SPACES FOR HANDICAP PARKING��
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? YE!Z4'
NO —
APPLICANT /1,71
-rint Name Ztilgn ure
TITLE _(TAIA Pp. DATE 14 X1:3=
Applications may be mailed in with a check, brought in person, faxed to 425-771-0266 or emailed to business.license@edmondswa.go
with a valid phone number. We will call you for a Visa or MasterCard payment. I 'Ilk
t
HOME PHONQ V-J&RIVERS LICENSE OR ID # & STAT
DATE OF BIRTH ;�-' / 4 1 [ CITY(STATE OF BIRTH I A W-11Jr 1A , f 'M --COUNTRY OF
PARTNERSHIP - PARTNER 1
NAME
LAST FIRST MIDDLE INITIAL
ADDRESS
STREET SUITEJAPTIUNIT # CITY/STATE/ZIP CODE
HOME PHONE( I DRIVERS LICENSE OR 10 # & STATE
DATE OF BIRTH CITY/STATE OF BIRTH � COUNTRY OF BIRTH
PARTNERSHIP - PARTNER 2
NAME
LAST FIRST MIDDLE INITIAL
ADDRESS
STREET SUITEIAPTIUNIT CITY/STATE/ZIP CODE
HOME PHONE( I ___----PRIVER'S LICENSE OR ID 9 & STA
CORPORATION/ LLC or PLLC
NAME OFCORPORATION FEDERALTAXD#
CORP,AODRESS
Street Suite, Apt. Unit# City, State and 7jp Gode Phone Number
CORPORATE OFFICERS:
Last Name First Name MI Title DatedBirth Driver's License or Other [D# /State
LOCALCON
Last Name First Name MI Title Dateof8idh
A
Driver's 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.LR.
COMMENTS
PLANNING DEPT.
APPROVE
DISAPPROVE
DATE
SIGNATURE
ZONING CODE
CONDITIONAL USE PERMIT
COMMENTS
POLICE DEPT, APPROVE DISAPPROVE DATE SIGNATURE —
COMMENTS
D- I I I-.*
R,wmil 1,
Rwnpl
35 4 3"
IN" N 1AW
1900 SqFt
16-11, x .19"
OU, x �21'
60".x 71"
114 " x Mll
IW�N 11""
Racalmm Ato
N
SNOHOMISH CO,
FIR
DISTR
Serving Brier, Edmonds, and
Mountlake Terrace
www..FireDistrictl.org
12425 Meridian Ave S
Everett, WA 98208
Phone (425) 551-1200 .
Fax (425) 551-1272
FIRE PREVENTION
__fflSPECTION REPORT
43EDMONDS
0 BRIER
[3 MOUNTLAKE TERRACE
[3 UNINCORPORATED
0' FREQUENCY
T( & SHIFT
LOCATION
221 James Street Sbite 100 98020
2015
[STATION
17-D
_R iMneiai.Se PHONE:
BUSINESS NAME:_B_& _jrfS--TF 4257718101
SCHEDULED
DATE DUE II, Dec 2015
C_y_
MAILING
UFIR 591
ADDRESS:
221 James Street, Suite 100, Edmonds, WA 98020
BUSINESS OWNER: HOME PHONE:
EMERGENCY-1: HOME PHONE
: 4257759048
00oo CURRENT
KEY ACCESS-2: HOME PHONE:
YES NO
CITY
EMAIL:
BUSINESS
LICENSE
PERSON CONTACTED:
INITIAL INSPECTION DATE
NAME OF INSPECTOR:
FIRE SYSTEMS: FE 4 / 1';�-
Date Last Serviced*
HAZARDS FOUND AND LOCATIONS/ COMMUNICATIONS
2
2
3
3.
4
4
. ... ..... . ..
6
5
6
7
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
lst RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTEDTO:
FINAL, RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
INSPECTOR:'
PERSON
CONTACTED:
INSPECTOR:
PERSON
CONTACTED:
1
2
INSPECTOR:
DATE:
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
4
7
18
3
7
RET RECEIPT
RECEI En
RATE
DISPOSITION:
6
8
7
LETTER NEEDED [:] YES NO
LETTER NEEDED [] YES NO
8
0- 4L�
Serving Brier, Edmonds, and 12425 Meridian Ave S
SNOHOMISHCO.
FIREMountlake Terrace Everett, WA 98208
Phone, (425) 551-1200
DISTR T www.FireDistrictl.org Fax (425) 551-1272
FIRE PREVENTION
IN PECTION REPORT
DMONDS
BRIER
[3 MOUNTLAKE TERRACE
[3 UNINCORPORATED
FREQUENCY
TATION & SHIFT_'�
LOCATION:
221 James Street. Suite 200 98020
2015
17-D
BUSINESS NAME:
4!�5 A.S -S eA 17-6 la.�HONE:
SCHEDULED
4257715813 Dec 2015
__yaeaTV-- .54A?
DATE DUE �
MAILING
591
ADDRESS: 221 James Street, Suite 200, Edmonds, WA 98020
BUSINESS OWNER: HOME PHONE:
EMERGENCY-1: Burrus, Ruth HOME PHONE:
4257505813 CURRENT
KEY ACCESS-2: HOME PHONE:
CITY
YES NO
EMAIL:
BUSINESS
11 El
LICENSE
PERSON CONTACTED:
INITIAL INSPECTION DATE
NAM E OFINSPECTOR:
FIRE SYSTEMS: FE
Date -Last SprV*rpil-
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
2
/00
t
2
3
3
4
4
5
6
5
6
7
7
I AGREE TO.CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
I st RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTEDTO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
�ERSON
CONTACTED:
PERSON
CONTACTED:
1
LNSPECTOR
INSPECTOR:
INSPECTOR:
2/1
DATE:
E:
DATE:
3
VIOLATIONS
5
VIOLATIONS-
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
6
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED
6
4
8
4
8
DATE:
DISPOSITION:
7
\1 LETTER NEEDED YES NO
LETTER NEEDED [3 Y�S 0 No
8
FIRE PREVENTION
Serving Brier, Ednionds
12425 Meridian Ave S
INSPECTION, REPORT
SNOHOMISH CO.
FIRE1".
Mountlake Terrace,and
Everett, WA 98208
0 EDMONDS
DBRIER
the Tb-i� . h of Woodway
Phone (425) 551-1200
0WOODWAY'
DISTR
[I MOUNTLAKE TERRACE
www.FireDistrict].org
Fax (425) 551-1272
0 UNINCORPORATED
"' FREQUENCY STATION & SHIFT')
LOCATION:
221 James Street
200
731 17 D
I
BUSINESS NAME:
Burrus Design Group
PHONE: 4257715813
SCHEDULED 12/01/11
DATE DUE
MAILING
221 James St #200
UFIR o 591 1;202
ADDRESS:
Edmonds
98020
BUSINESS OWNER:
Burrus, Ruth
HOME PHONE: 4257505813
ACTIVE
EMERGENCY-1:
Cetina, Doug
4258682317
HOME PHONE:
CURRENT
KEY ACCESS-2:
HOME PHONE:
CITy YES NO
BUSINESS
El El
LICENSE
PERSON CONTACTED: Z�
INITIAL INSPECTION DATE
NAME OF INSPECTOR:
FIRE
FE
SYSTEMS:
ANNUAL
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
2
2
- 3
3
4
4
5
5
6
6
7
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
11st RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTED TO:
FINAL RE -INSPECTION
DATEDUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
1
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
I
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
14
18
4
8
DATE,
DISPOSITION:
7
LETTER NEEDED C] YES El NO
I LETTER NEEDED F] YES [I NO
r
8
FIRE DEPARTMENT COPY