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RECIFIVED CITY OF EDMONDS 1:1 Building
PUSINESS LICENSE APPLICATION - COMMERCIAL
1. 0 Engineering
JAN 2 6 2 FEE: $125.00 0 Fire
0 Planning
CITY CLERK'S OFFICE, BUSINESS LICENSE DIVISION 0 Police
EDMONDS VENUE NORTH, EDMONDS, WA 98020 PHONE 425.775.2525
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0ou OFFICE USE ONLY
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Customer
SIC
I Year
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Class
SHD
Date Paid
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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 fee. 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
BUSINESS
MAILING ADDRESS _r
07 14WV &JI I-- o rj oz,, w A Itao 2-
Street dr PO Box 4 Suite City, State. Zip Code
WA STATE TAX ID # (UBI)
BUSINESS PHONE(4r DE) 2Z�_ Sk
BUSINESS E-MAIL
BUSINESS OWNER( CONTACT
_�MAIN Name
Phone Number
PROPERTY OWNER[;LIA G41PQ AOL RDL.0 I Zcyy-) AQ?5) 49.? -176 IF
Name Phone Number
EMERGENCY NOTIFICATION (For Premise Access in�mergency):
Lj()r4)6�1
'12- -fQ:Z 05 2 3
L
Last Name - I — First Name MI Phone Number
NATURE OF BUSINESS (Provide a Detailed Description of Business Activities, Products & Services),\d
PREVIOUS BUSINESS AT THIS ADDRESS 1 'r 11'- 115m 2�m�. �1 r-%
NUMPERQFfMPLOYEES I Q h - . , SQUARE FOOTAGE OF BUSINESS
Wo r k, ; Y% ID U- t.-,
TYPE OF SU= — PLEASE CHECK APPROPRIATE CATEGORY:
o
CONSTRUCTION
n
FINANCE, INSURANCE, REAL ESTATE
El
LANDSCAPE, HORTICULTURAL
•
MANUFACTURING
•
NON-PROFIT
•
RETAIL
•
SECONDHAND DEALER
SERVICES
•
WHOLESALE
•
OTHER
PROP9SED OPENING DATE.- '13017-11311-7
If� b usi ivz 4-1� ' ) *0,,.l 3
BUSINESS HOURS: 1 00 ��'on
DAYS OPEN: .
o SUNDAY is� WEDNESDAY
'N MONDAY -Is� THURSDAY
"h1TUESDAY N FRIDAY
USATURDAY
AMUSEMENT DEVICES 014 PREMISES? YES— N0_IF YES; TOTAL NUMBER —LIQUOR SOLD ON PREMISES? YES— NO_�!�
GAMBLING? YES NO
CIGARETTES SOLD ON PREMISES? YES
FLAMMABLE OR.HAZARDOUS MATERIALS USED OR�STORED? YES— No��_ IF YES, PLEASE PROVIDE A LIST OF MATERIALS AND QUANTITIES!,
PARKING SPACES ON SITE: TOTAL SPACES 3C) ACCESSIBLE SPACES FOR HAND l(� P PARKING
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? YE NO —
APPLICANT
NAME 0
TITL Wed M5 werli-01- DATE—)
SOLE PROPRIETORSHIP
NAME
LAST FIRST MIDDLE INMAL
ADDRESS
STREET SUITEIAPTIUNIT # CITY/STATE/ZIP CODE
HOME PHONE( RIVERS LICENSE OR ID 4 & STATE
DATE OF BIRTH CITY/STATE OF BIRTH COUNTRY OF BIRTH
PARTNERSHIP — PARTNER 1
NAME
LAST
FIRST
MIDDLE INITIAL
ADDRESS
STREET
SUITEIAPT/UNIT#
CrrYJSTATE/ZIP CODE
HOME PHONE(
—DRIVERS LICENSE OR ID N & STATE
DATE OF BIRTH
____CITY/STATE OF BIRTH -------COUNTRY OF BIRTH
PARTNERSHIP — PARTNER 2
NAME
LAST
FIRST
MIDDLE INITIAL
ADORES
STREET
SUITE/APT/UNIT 0
CITY/STATEIZIP CODE
HOME PHONE(
LICENSE OR 10 # & STATE
I DATE OF BIRTH
CITY/STATE OF BIRTH COUNTRY OF BIRTH
CORPORATION( LLC
)r PLLC
NAME OFCORPORATION—C61-0-
S�erv;us
JX ID4 —44,25.5,
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W.
CORP.ADDRESSQJ
Street
Suite, Apt. Unit#
City, State and Zip Code Phone Number
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CORPORATE OFFICERI
Last Name
First Name
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Mi Alle
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Dateof Driver's Licen e or Other ID# /State
Tr5lo!54
MCI AN
ALVIN[ (M-A).)
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LOCAL CONTACT
OPeAATJ
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'CIO
Last Name
T,
First Name
as 'S
M-1 Title
DateofBirth
lip
(7D2 '3
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.FJ.R,
COMMENTS
PLANNING DEPT,
APPROVE
DISAPPROVE
DATE
—SIGNATURE
20NING CODE
CONDITIONAL USE PERMIT
COMMENTS
POLICE DEPT. = APPROVE = DISAPPROVE DATE SIGNATURE
COMMENTS—
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MECEIVED:
AN 2 5 2-017
EDMONDS CITY CLERK
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