22937 HWY 99 STE CC�;GF
BUMMESS UCEMSEAPPUCATOM - CONNERMAL
FEE, $120.00
CITY CLERK'S OFFICE, BUSINESS LICENSE DIVISION
121 5T' AVENUE NORTH, EDMONDS, WA 98020 PHONE 425.775.2525
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INSTRUCTIONS: Please complete the application in full and aftch the required floor plan. Middle initial or name required of all parties concerned. It no
middle name, please indicate by writing MUM Sign and return application with fee. Please advise of any change In status. Novi license required If
business changes location or ownership. Notification to City of Edmonds required If business closes. License expires December 31" each year. Renewal
must be submitted prior to January 31D'to avoid late fees.
BUSINESS NAME.
BUSINESS ADDRESS__,'J� 41 54a �'Wo 4
Street
Suite
Code
MAILING ADDRESS
Street or PO BOX # Suite City. State, Zip Code
BUSINESS PHONE( _d' 7 0 WA STATE TAX ID # (UBI) 0 L
� 13 131
BUSINESS E-MAIL 0117(A liegO d r4) �,:4 BUSINESS WESSITE
BUSINESS OWNER / MAIN CONTACT /\j A th T -y19b
Name Phone Number
EMERGENCY NOTIFICATIONfor Premise Access In Emergency)
Last Name First Name Ml Phone Number
7,1..P erl
Fa-st-Ram-el First Name MI Phone Number
NATURE OF BUSINESS (Provide a Detailed Description of Business Activities, Products & Services):
I u4,H c(�
1i
SPACE ALTERATIONS TO BE MADE: YES_____�NQ__ DESCRIPTION
PREVIOUS BUSINESS AT THIS
NUMBER OF EMPLOYEES e�
SOUA6 FOOTAGE OF BUSINESS SPACE-
A4- -A� Pe
TYPE OF BUSINESS - PLEASE CHECK APPROPRIATE CATEGORY:
• CONSTRUCTION
• FINANCE, INSURANCE, REAL ESTATE
11 LANDSCAPE, HORTICULTURAL
r-1 MANUFACTURING
r_ NON-PROFIT
RETAIL
SECONDHAND DEALER
Li SERVICES
r_ WHOLESALE
r] OTHER
PROPOSED OPENING
BUSINESS HOURS:
DAYS OPEN:
134SUNDAY U WEDNESDAY
L4 MONDAY 6' HURSDAY
1!rTUESDAY FRIDAY
EYSATURDAY
AMUSEMENT DEVICES ON PREMISES? YES— NO — IF YES, TOTAL,4UMBER LIQUOR SOLD ON PREMISES? YES�__ NO._L__f_
GAMBLING? YES— NQ/" CIGARETTES SOLD ON PREMISES? YES Iz"
FLAMMABLE OR HAZARDOUS MATERIALS USED OR STORED? YES— NQ_ IF YES, PLEASE PROVIDE A LIST OF MATERIALS AND QUANTITIES:
PARKING SPACES ON SITE: TOTALSPACE ; '1�_ ACCESSIBLE S ES FOR HANDICAP PARKING
S]U S �BLETO P
DOES THE BUSINESS CONTAIN AN ENTRANCE: ACCtS RINS WITH DISABILITIES? YES-,--- NC_
APPLICAMT
.1 �)
NAMIE— dtv( AM 01-4 0
Printed Name Signs
TITLE DATE 2 C2
Applications may be mailed In bvith a check, brought In person, faxed to 425-771-0266 or emaiPed to bustnesslicense@edmondswa.
with a valid phone number. We wifl callyou for a Visa or MasterCard payment.
SOLE PROPRIETORSHIP
NAME LAST FIRST MIDDLE INITIAL
ADDRESS STREET SUJTEIAPTIUNIT # CITY/STATEIZIP CODE
HOMEPHONE DRIVERS LICENSE OR ID # & STATE
DATE OF BIRTH __�CITY/STATE OF BIRTH ----jCOUNTRY OF BIRTH
PARTNERSHIP —
NAME LAST FIRST MIDDLE INITIAL
ADDRE STREET SUITE/APTIUNIT # CITYISTATE/ZIP CODE
HOME PHONE( I DRIVERS LICENSE OR ID # & STATE
DATE OF BIRTH CITYISTATE OF BIRTH -- -COUNTRYOFBIRTH
PARTNERSHIP — PARTNER 2
NAME LAST FIRST MIDDLE INITIAL
ADDRESS
STREET SUITE/APTIUNIT CITY/STATOZIP CODE
HOME PHONE( I - -DRIVER'S LICENSE OR ID * & STATE
NAME OFCORPORATION. A- CORPORATION/ LLC or PLLC
-Z I— C FEDERALTAX D#
'32 52)l Hwy qq a
CORP.ADDRESS 04-rY, 64 4MP�)6
street Suits, Apt, Unit# City, State and Zip Code Phone Number
CORPORATE OFFICERS:
Last Name First Name Ml Title DateofB!rth Drivers License ar Other ID# /State
L
A v 1� Y. D T Q Myl AVG C
LOCAL CONTACT
Last Name First Name Ml Title DateofBhh
If
Driver's License or Other ID9 IState 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
LIT
COMMENTS
PLANNING DEPT, APPROVE DISAPPROVE DAT SIGNATURE —
ZONING CODE — CONDITIONAL USE PERMI COMMENTS
POILICE DEPT. APPROVE DISAPPROVE DAT SIGNATURE —
COMMENTS
STAXES 01F.44
'09
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of cc)
Secretar*vy"" of State
1, KIM WYMAN, Secretary of State of the State of Washington and custodian of its
seal, hereby issue this
CERTIFICATE OF FORMATION
to
AZEEM LLC
a/an WA Limited Liability Company. Charter documents are effective on the date
indicated below.
MPH%
ft
pe�
Ma
IN:
AM:
"OHN:
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IN,
Date: 4/27/2016
UBI Number: 603-612-633
Given under my hand and the Seal of the State
of Washington at Olympia, the State Capital
Kiiii Wynian, Secretary of State
Date Issued: 4/27/2016
8 +== M
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0
LA-
35 ft
3:
Floor Plan
0
business Name
Smoke n Vape
22937 Hwy 99 North
Edmond WA 98026
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MMM -000,
35 ft
12 ft
12 ft
Storage
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Storage
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SNOHOMISH CO.
Serving Brier, Edmonds, and
Mountlake Teri -ace
www.FireDistrictl.org
LOCATION:
22937 Highway 99 98026
BUSINESS NAME: All Nesian Market
MAILING
ADDRESS:
22937 Highway 99, Edmonds, WA 98026
BUSINESS OWNER:
12425 Meridian Ave S
Everett, WA 98208
Phone (425) 551-1200
Fax (425) 551-1272
PHONE: 4256402944
HOME PHONE:
FIRE PREVENTION
INSPECTION REPORT
OEDMONDS
0 BRIER
0 MOUNTLAKE TERRACE
[3 UNINCORPORATED
FREQUENCY STATION & SHIFT
2016* 20-C
SCHEDULED
DATE DUE 0 Apr 2016
UFIR � 526
EMERGENCY-1:
Selifis, Rosendo
HOME PHONE:
4257736565
CURRENT
YES NO
KEY ACCESS-2:
HOME PHONE:
CITY
8USINESS
EMAIL:
LICENSE
INITIAL INSPECTION DATE
PERSON CONTACTED:
/_ /
NAME OF INSPECTOR:
7
FIRE SYSTEMS: FE 5/13
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
In our continuing effort to promote fire safety and prevention within the community, your fire department conducts
regularly scheduled "Fire Safety Survey Inspections" of all.businesses and multi -family occupancies in the Cities
covered by Snohomish County Fire District 1.
You are to be congratulated on the relative good condition of your occupancy in regards to fire safety. Above you
will find the item(s) that were noted during, our inspection which require attention to bring them into compliance
w ith the minimum standards adopted by the above jurisdictions.
Any overlooked hazards or violations. of the fire regulations does not imply approval of such conditions or violation.
If you require additional information or to schedule a re -inspection for Edmonds, call (425) 775-7720; for
Mountlake Terrace or Brier, call (425) 744-6231.
Serving Brier, Edinonds
Mountlake Terraceand
0).. the Town of Woodway
aT www.FireDistrictl.org
-FIRE-PREVENTION
MPtCTION REPORT
12425 mel-idian' Ave s
DEDIVIONDS
Everett, WA 98208 0 BRIER
Phone (425) 551-1200 0WOODWAY
[I MOUNTLAKE TERRACE
Fax (425) 551-1272 0 UNINCORPORATED
FREQUENCY
STATION 1, SHIFF",
LOCATION:
22937 Highway 99
366
20
I
D
BUSINESS NAME:
All Nesian Market
PHONE:
4256402944
SCHEDULED
DATEDUE � (3410-1/13
MAILING
22937 Highway 99
UFIR � 526 4056
ADDRESS:
Edmonds
98026
C42, 6) 1 7?� -
BUSINESS OWNER:
Selifis, Rosendo
HOME PHONE:
2056V37382
ACTIVE
EMERGENCY-1:
Ryu, Cody/Cindy
HOME PHONE:
2069303957
KEY ACCESS-2:
HOME PHONE:
[—g—RRENT
ITY YES
NO
BUSINESS
Z'
EL
LICENSE
PERSON CONTACTED:
INITIAL INSPECTION DATE
NAME OF INSPECTOR:
�5
FIRE
FE
SYSTEMS:
ANNUAL
HAZAPS FOUND AND LOCATIONS / COMMUNICATIONS
'r
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 ,-, , �_J�f
1st RE-INSPECTI
-DATE DUE:
2nd RE -INSPECTION
DATE DUE:
,
EXTENSION
GRANTED TO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
1
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
-DATE�
3
VIO 10 S
1
VIOLATIONS
15
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
12
6
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED
6
4 18
(A
4
8
IDATE:
DISPOSITION:
7
1� LETTER NEEDED F] YES )y NO
rLETTER NEEDED [I YES NO
I 1
8
I( FIRE DEPARTMENT COPY
CITY OF EDMONDS
U INES LICENSE APPLICATION— COMMERCIAL
. FEE: $125.00
TH CITY CLERK'S OFFICE, BUSINESS'LICENSE DIVISION
121 5 AVENUE NORTH, EDMONDS, WA 98020 PHONE: 425.775.2525
0 5 7
OFFICE USE ONLY
IBL#
1�2.7n,;2/7
ustomer#
1413C9,9
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Class
6
SHO
1
I Date Pald
VA-AV-12_PQQ0J&_5_
TR#
Fee Paid
JeRs— 00
MaIW
1
Delete
1. 1
INSTRUCT10INS: Please complete the application In full and attach the required floor plan. Middle initial or name required of all
parties edricerried. If no middle name, please Indicate by writing NMN. Sign and return application with fee. Please advise of -
any change In status. Now license required If business changes location or ownership. Notification to City of Edmon& required
lfbuslness tJoses. -1?ej_-h(4Lkk
BUSINESS NAME
BUSINESS ADORES
MAILING ADDRESS
S o6 14� WV CA
'Street Suite NO. Zip Code
Street of PO Box SulteNo. City, State andWuou.
BUSINESS PHONE NO. kcn
BUSINESS E-MAIL 4 BUSINESSWEBSITE
kOPER'TY OWNER (ADCO
EMERGENCY NOTIFICATION (For Premise Acmss in Emaroenavi-
NUMBER 6PEMPLOYE&§ _R:�E�SQUARE F0O`rAGE OF BUSINESS SPACE
TYPE OF BUSINESS - PLEASE CHECK7HE APPROPRIATE CATEGORY:
CICONSTRUCTION' d FINANCE, INSURANCE.IkEAL ESTATE-, 13LANDS.CAPE. HORTICULTURAL
13 MANUFACTURING C3 NON-PROFIT
.0 RETAIL,/ Ci seCON6MMO DEALER 0 SERVICES 13 WHOLESALE (3,OTHER
AMU$EMENT DEVICES'ONVREMISES? d YES (3 NO IF YES. TOTAL NUMBER
LIQUOR SOLD ON PREMISES?: O�ES, )(140.' GAMBLING? 13 YES 0 CIGARETTES S'OLD-ON PREMISES? 0 YES NO
N
FILAMMA13LE OR HAZARDOUS MATERi)kLS WEDOR STORED?: DYFS?(NO IF YES. PLEASE PROVIDE LIST OF MATERIALS AND QUANTI'nES:
PROPOSED OPENING DAY -OF BUSINESS Z k)VISP— QBUSINESS HOURS
DAYS OPEN 0 SUNDAY '"OmDAY
ATUESDAY �ZWEDNESDAY ITHLIRsDAY YFRiDAY SATURDAY
PARIONG SPACES ON SITE; TOTAL LQ 7- ACPESS113LE FOR PERSONS WITH DISABILITIES
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISAB!UTIES? YES 0 NO
PREVIOUS BUSINESSUSE AT THIS ADDRESS �- &' A(a Av
il
SOLE PROPRIETORSHIP
Last First
ADDRESS
Street Apt No., Unit No. City. State and Zip Code
HOME PHONE NO. DOL NO. (DRIVERS LICENSE NO.) OR OTHER ID NO_
DATE OF BIRTK____ClTY AND STATE OF BIRTH __pOUNTRY OF BIRTH
PARTNERSHIP - PARTNER i
lkT �_A __
Lam First MI
ADDRE$S
Sbad Apt. No.. Unit No. City. State and Zip Code
HOME PHONE NO.( _____POL NO. (DRIVERS LICENSE NO.) OR OTHER ID NO. —
DATE OF BIRTHL—CITY-AND STATE OF BIRTH COUNTRY OF BIRTH
PARTNERSHIP - PARTNER 2
ADDRESS
Street Apt. No.". Unit No. City. State and Zip Coft
HOME PHONE NOJ DOL NO. (DRIVERS LICENSE NO.) OR OTHERID NO.
DATE OF BIRTH —CITY AND STATE OF BIRTH �_�COUNTRY OF 81
CORPORATION
NAME OF CORPORATtO -FEDERAL TAX ID NO,ft
j r
CORP. ADDRESS_M 0��
_AILQ141A� J-!.q !Ic&;. RIGNE Ne.(
SWO. APO. Unit No; City; State and 7Jp e
CORPORATE OFFICERS:
LaStNama, First Name MI Me OkkofBirth DOL Mo. 'Drivers License No.) or Other,10 NO.
(�it- — Qg�&QL I A I ark I I-VP.4(
e- -�(_%b Sr=Ll F&k3�06
LOCAL COffrACT-,5_rL;f-;5 -RD-SL d
Last Name First Name W Twe LPhonek DOL No. (Drivers LIc. No.) or Other 10 No
'APPjbANT-.fpl
E2_
Name pdnw
rit!e Date
7.
CITYUSPONLY:
PLAN G, '111S 6
bAfk.
7
ZON
.:CONDIfiONALUStPERM
BUIPING:dEPTx MAPPROVE
0 DISAPPROVE
DATE
_SIGNATUAE
OC61MANT LOAk - -. _-jBUILOIkG
P , ERMIT
PANCY GROW
CO
FIRE DEPT. ..13APPRQVE
13 DISAPPROVE
OATEL��-
�SIGIiATUR'
U.FJ.R. -
COMMEkTS
POL"Cl�pErT_ GAPPROVE -
0 DISAPPROVE
DATE
SIGNATURk__�....
COM&Iwjfri
4+vo)(
CITY OF EDMONDS
121 STH AVENUE N. - EDMONDS, WASHINGTON 98020 - (425) 771-0215
FIRE DEPARTMENT
LOCATION: 22937 Highway 99
BUSINESS NAME: Mundo De Juguete
MAILING 22937 Highway 99
ADDRESS: Edmonds 98026
BUSINESS OWNER: Antonio, Arroyo HOMEPHONE: 4256731034
EMERGENCY-1: _fbyu, Cody/Cindy HOMEPHONE: 2063628832
KEY ACCESS-2: HOME PHONE:
FIRE PREVENTION
SAFETY SURVEY
PHONE: 2066837336
FREQUENGY
STATION 1, SHIFT
366
20 6
I
SCHEDULED
DATE DUE 0
04/01/11
LIFIR 0, 526
4056
AC'nVE
e INITIAL INSPECTION DATE
PERSON CONTACTED:
NAME OF INSPECTOR:
FIRE FE — I — .
SYSTEMS: A14NUZ
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
1
ENTER CODE ONLY ONCE ll�
VIOLATION CODE
1 1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
lst 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:
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
7
4
18
4 18
1 DATE:
DISPOSITION:
LETTER NEEDED E] YES E] N
[�TTER NEEDED 0 YES NO
FIRE DEPARTMENT COPY -
164 —%dV—
CITY OF EDMONDS
121 5TH AVENUE N. - EDMONDS, WASHINGTON 98020 (425) 771-0215
FIRE DEPARTMENT
4j' t
LOCATION: 22937 Highway 99
BUSINESS NAME: Mundo De Juguete
MAILING 22937 Highway 99
&MMOM00
FIRE PREVENTION
SAFETY SURVEY
PHONE: 2066837336
Edmonds 98026
BUSINESS OWNER: Antonio, Arroyo HOMEPHONE: 4256731034
EMERGENCY-1: Ryu, Cody/Cindy HOMEPHONE: 2063628832
KEY ACCESS-2: HOME PHONE:
FREQUENCY
STATION& SHIFT
366
20 A
SCHEDULED
DATE DUE 11-
04/01/10
LIFIR 1" 526
4056
ACTIVE
01 INITIAL I INSPECTION'DATE
PERSON CONTACTED:
NAME OF INSPECTOR: VIIIJ 0 tj I P—) - k CD
FIRE
SYSTEMS:
FE
ANNUAL
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
ENTER CODE ONLY ONCE I�
VIOLATION CODE
v P-\(-
2
2
3
3
4
4
5
6
6
7
7
8
8
lst RE -INSPECTION
2nd RE -INSPECTION
EXTE
3E-INSPECTION
VIOLATIONS
GRANI
CITED:
DATE DUE:
PATE DUE:-------.
PERSON
UE:
PERSON
PERSON
CONTACTED:
CONTACTED-
INSPECTOR:
R�TE:
CONTACTED-
INSPECTOR:
1
2
INSIDE TOR:
DATE:
L__ DATE:
3
VIOLATIOI4S___
____ — ___ __
MOLATIONS
PRE -CITATION CITATION ISSUED
1 5
1 5
LETTER SENT
NUMBER:
4
CODE
5
2 6
2 6
- ------ - - ------- - - -_---_- -- __ --------
DATE:
SECTION:
RETURN RECEIPT
6
3 7
.3 7.
RECEIVED
7
DISPOSITION:
4 8
4 8
rUETTER NEEDED E] YES E] NO
DATE:
8
LETTERNEEDED [] YES ONO
FIRE DEPARTMENT COPY