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22902 75TH AVE W
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-CITY of EDMONDS BUSIN&TIQ PH�I%ATION LICENSENO.
4WA, . -
Civic Center * Edmonds, Washington ziovzu ANNUAL FEES PENALTY AFTER FEB. 15
City'Clerk Phone 775-2525
0 HOME OCCUPATION
CLASSIYEARI LIC. EFFEC. DATE REASC, LIC NO SPEC $10.00 (A) ADDITIONAL $5.00 0
INSTRUCTIONS:
I SMALL BUSINESS
e All items must be completed
RECEIPT NO, DATE PAID 'X' A� $15.00 (B) ADDITIONAL.$7.50 1i
6
or application will not be ac- PRINTP
IF_ � I , , -_` IN S EC. BOX
�) IC / V. )v, I/ 1/ 0 Business with 10 or
cepted. , 1 / � I FOR ISSUE OF
FEE PAID PENALTY PAID CORRECTED
more employees ADDITIONAL $25.00 0
* Sign and return application I LICENSE WITH $50.00 s
with fee. Renewals received L_ I /I I I 'LC'ACTION. (C)
after February 15 must pay 0 NEW APPLICATION (LA)
penalty in addition to fee. N RENEWAL (LB)
NEW BUSINESSES AFTER 0 CHANGE (LC)
JULY 31, 1/2 FEE. (PLEASE MAKE ANY NECESSARY CHANGES) 0 DELETE (LD)
NAME OF FIRM BUSINESS PHONE OF EMPLOYEES
I F- Y S A V E`R S P I I R i'-1 �4 C Y 1 7'1 5
MAILING ADDRESS NATURE OF BUSINESS
PHARMACY
7 V I; rrrl-
Em, nN D S I�A .93020
ADDRES
BUSINESS es INDIVIDUAL PARTNERSHIP CORPORATION
o:
EM� (S) (P) P
t _�i � -f - .
OWNERS NAME HOME ADDRESS
r� ly '1 ;??')07 15TH A\/ N
HOMEPH ONE DATE OF BIRTH PLACE 6P di-Fifl-P S AL �V�_URITM'MUBER
SOCI 17
EMERGENCY NOTIFICATION: (1) NAME & TELEPHONE NIC C "Y J 7 1)--�448
(PLEASE LIST TWO) (2) NAME & TELEPHONE, r�(, "Y J 206- 776-0 16P
APPLICANT'S SIGNATURE"'
WASHINGTON STATE TAX NO. -
DO NOTMITE BELOW THIS. LINE 6z
STAFF REVIEW: FILL IN LAND USE CODE, LIFIR 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
P-APPROVE El DISAPPROVE SIGNATURE -)I
Ap p /'0 v A C (0 V,--, 0 tlx S CONDITIONAL USE PERMIT
0 AJ
COMMENTS
L DING DEPARTMENT
' DATE
Building
El
Hotel/Motel
(L)
APPROVE El, DISAPPROVE SIGNATURE
Permit.
El
Apt. Bldg.
(A)
El
Office Bldg.
(0)
-e
Occupancy
El
Restaurant
(R)
COMMENTS:
Group
El
Hosp/Nurs Home
(H)
CAPACITY: (NO. UNITS, APTS., OFFIdS; SEATS, BEDS, STUDENTS)
El
School
(S)
FIRE DEPARTMENT DATE
0 APPROVE 0 DISAPPROVE SIGNATURE
COMMENTS-,
POLPf DEPARTMENT DATE 2Z _Z� SIGNATURE
PIPPROVE 0 DISAPPROVE
IM,ENTS:
' LIC WORKS DEPARTMENT
BAOPR,OVE 0 DISAPPROVE DATE -31" SIGNATURE
COMMENTS:
U.F.I.R.
A
ILE APPLICATION
f—%'rREET F for
The City of Edmonds SIDE SEWER PERrdlT
OUTSIDE.Zf INSIDE 0 REPAIRS 0
CARD No . .......................................
EASEMENT No . ...................................... *
OV,rNER ....... Rb .. L .............. 6; - -------- 04.-)
1.4.7 ........................... CONTRACTOR ...... 01110,4.',2-."'�� ............................................... ........... ..... PERMIT No.
STREET
HOUSE No . ..... 6U,24�-X -------------- 7,s .... We'-Ift ................... ............. AVENUE LOT No . ...................... A? ----------------------------------------- BLOCK No. .1 ...................... i ................
NAME ADD. ------- -A
............ ----------------------------
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Date
BACKFILL WORK ORDER ISSUED ...................................
SEWER WORK ORDER ISSUED ..................................
5 77
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-ID
AlA'
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ROVED
Approved:
DEPOSIT, $ .............................................
ADATE BY ----------------------