23607 HWY 99 STE 2A- . 14
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RECEIVED CITY OF EDMONDS
NOV B FEE: $125.00 - COMMERCIAL
7 ffINESS LICENSE APPLICATION
CITY CLERK'S OFFICE, BUSINESS LICENSE DIVISION
nUn%lnQ V1TWfVt.WNUE NORTH. EDMONDS, WA 98020 PHONE 425.775.2525
•
Building
•
Engineering
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Pilalrining
Police
OFFICE USE ONLY
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Customer # sic
31900
Year
Class
I OSCHD
Date Paid
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Mailed
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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. If no
middle name, please indicate by writing NMN. Sign and return application with foe. Please advise of any change In status. New 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 31" to avoid late fees.
BUSINESS NAME c,%R Lies s. ww , s.
P
BUS,NESSADDRESS (icl A Eo�mi;
Street Suite # City, State, Zip Code
MAILING ADDRESS
Stre t or PO Box N Suite # City. State. Zip Code
BUSINESS PHONE( q WA STATE TAX ID # (UBI) I I I -Z- I ii I g I
IA 6101( NI \Is-]
BUSINESS E-MAIL T1 -Wkk-VfT1--X R- 11 --T. I &- -
BUSINESS OWNER / MAIN CONTACT
Narne
PROPERTY OWNER T- � I- � A 44
EMERGENCY NQTIFICATION (For Premise Access in E
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t-A-1
L- lloi6
Phone NVrn
Last Name ' ") First Name MI Phone NUMDer
NATURE OF BUSINESS (Provide a Detailed Description of Business Activities. Products & Services):
<:�: �A 1k—F,0 1Z
SPACE ALTERATIONS TO BE MADE: YES —NO— DESCR
PREVIOUS BUSINESS AT THIS ADDRESS
NUMBER OF EMPLOYEES In SQUARE FOOTAGE OF BUSINESS SPACE
TYPE OF BUSINESS - PLEASE CHECK APPROPRIATE CATEGORY
0 CONSTRUCTION
11 FINANCE, INSURANCE, REAL ESTATE
• LANDSCAPE, HORTICULTURAL
• MANUFACTURING
• NON-PROFIT
• RETAIL
• SECONDHAND DEALER
• SERVICES
• WHOLESALE
• OTHER
PROPOSED OPENING
BUSINESS HOU
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Phone Number
( ')-0 &
Phone NiTrnber
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tool
DAYS OPEN:
LiSUNDAY o WEDNESDAY
• MONDAY o THURSDAY
• TUESDAY ij FRIDAY
o SATURDAY
AMUSEMENT DEVICES ON PREMISES? YES NO_�t/IF YES. TOTAL NUMBER LIQUOR SOLD ON PREMISES? YES_ NO_
GAMBLING7 YES_ NO V, 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— ACCESSIBLE SPACES FOR HANDICAP PARKING
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? YES— NO
aml 4 APPLICANT
NAME 44 C' C' - �4 L,- 1),
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TITLE DATE
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C-'� I
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SOLE PROPRIETORSHIP Zc%.jaj%,z 1)
NAME LAST FIRST MIDDLE INITIAL NOV 7 2mb
ADDRESS STREET SUITE/APTIUNIT # CITYISTATEIZIP CODE t0imow enfly
HOME PHONE( DRIVERS LICENSE OR ID # & STATE
DATE OF BIRTH ____SITYISTATE OF BIRTH COUNTRY OF BIRTH
PARTNERSHIP — PARTNER 1
NAME
LAST FIRST MIDDLE INITIAL
ADDRESS
STREET SUITEIAPT/UNIT # CITY/STATE)ZIP CODE
HOME PHONE( I 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/APT/UNIT # CITY/STATE/ZIP CODE
HOME PHONE( —DRIVER'S LICENSE OR ID # & ST
ATE
CORPORATION/ L C or PLLC
00 P,(;, —FEDERALTAXID# C,
NAME OFCORPORATION.
CORP.ADDRESS 69 If
Sjeet �uite,Apt. Unitti City. St le and Zip Code Phone Number
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CORPORATE OFFICERS:
Last Name First Ne Title Daleof &rth,/ / Driver's License or Qlher ID# / Slat
w o Umf—<, <� Wks 411% Cn 14 IAW 44-CSSOUL:
LOCALCONTACT S �C�, �- 0�5 7 �� �,
Last Name First Name MI Title Dateof Birth
CITY USE ONLY:
BUILDING DEPT.
OCCUPANTLOAD
/ State
APPROVE = DISAPPROVE DA
BUILDING PERMIT
SIGNATURE
OCCUPANCY GROUP
ENGINEERING
APPROVE
DISAPPROVE
DATE
SIGNATURE_
FIRE DEPT.
APPROVE
DISAPPROVE
DATE
SIGNATURE_
U.F.I.R.
COMMENTS
PLANNING DEPT.
APPROVE
DISAPPROVE
DATE
SIGNATURE -
ZONING CODE
CONDITIONAL USE PERMIT
COMMENTS
POLICE DEPT.
APPROVE
DISAPPROVE
DATE
SIGNATURE -
COMMENTS
RECEIVED
NOV 7 2016
EDMONDS CITY CLERK
im
� I %,
SNOHOMISH CO.
� 11
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
INSPECTION REPORT
0 EDMONDS
[I BRIER
0 MOUNTLAKE TERRACE
[3 UNINCORPORATED
FREOUENCY
STATION & SHIPT-*)
LOCATION:
23607 Highway99 Suites 2A-2C 98026
26116
26 A
BUSINESS NAME:
PHONE:
SCHEDULED
0
Melby, Cameron & Hall
4257747479
DATE DUE
AiR
2016
MAILING
UFIR 0
ADDRESS:
591
23607 Highway 99, Suites 2A-2C, Edmonds,
WA 98026
BUSINESS OWNER:
HOME PHONE:
Melby Cameron Co.
.EMERGENCY-1:
HOME PHONE:
CURRENT
KEY ACCESS-2:
HOME PHONE:
CITY
YES NO
BUSINESS
EMAIL:
LICENSE
INITIAL INSPECTION DATE
PERSON CONTACTED:
NAME OF INSPECTOR:
FIRE SYSTEMS
61; 3
UQftftCI3S�tCb"0CbCATIONS
/ COMMUNICATIONS
2
2
3
4
�J� V V
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3
5
5
6
6
7
7
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. /Ae you
v �
will find the item(s) that were noted during, our inspection which require attention to bring them into c pliance
with 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.