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23621 79TH AVE W
BUSI&I L �V-
-, 110ENSF-APPLICAT[ON
CITY OF EDMONDS
250 5TH AVENUE NORTH
EDMONDS, WASH. 98020
TELEPHONE (206) 775-2525
FILE
INSTRUCTIONS
I PRINT APPLICABLE LICENSE CLASS. FEE AND PENALTY PAID
IN ANNUAL FEE BOX AT RIGHT. PENALTY DUE ON RENEWALS
RECEIVED BY CITY CLERK AFTER FEBRUARY 15. -
2. NEW BUSINESS: COMPLETE ALL LICENSE APPLICATION BOXES.
LIC. RENEWAL: REVIEW LICENSE INFORMATION BELOW. PRINT
CORRECTIONS AND ADDITIONS AT RIGHT.
i SIGN AND RETURN APPLICATION WITH FEE (AND PENALTY).
A. LICENSE WILL BE MAILED TO YOU UNLESS YOU ARE NOTIFIED
TO APPEAR FOR APPLICATION REVIEW.
LICENSE RENEWAL
REVIEW BELOW INFORMATION. PRINT CHANGES AT RIGHT.
IT
"_� ANNUAL FEES-----")
TYPE BUS. CLASS
FEE
PENALTY
HOME A
$10.00
S 5.00
SMALL B
15.00
7.50
'GENERAL C
50.00
25.00
NAME SOCIAL SECURITY NO.
DATE OF BIRTH PLACE OF BIRTH
'HOME ADDRESS
3. BUSINESS IDENTIFICATION
; BUSINESS NAME
WASH. STATE TAX NR. I EMPLOYEES I ORGAN. IOCCUPANCY
TYPE ORGANIZATION
C CORPORATION
L LTD. PART
P PARTNERSHIP
S SOLE OWNER
If BUSINESS IS:
HOTEL/MOTEL
APT.BLDG.
OFFICE BLDG.
RESTAURANT
HOSP./NURS. HOME
SCHOOL
4. BUSINESS ADDRESSES
BUSINESS ADDRESS
LICENSE MAILING ADDRESS
'OVER 10 EMPLOYEES, OR BMPL WORK
OVER 120 MAN -MONTHS PER YEAR.
CLASS FEE PAID PENALTY PAID
TYPE
CAPACITY
L
NR OF ROOMS/UNITS
A
NR OR APTS
0
NR OF OFFICES
R
NR OF SEATS
H
NR OF BEDS
S
NR OF STUDENTS
5. EMERGENCY NOTIFICATION
NAME AREA TELEPHONE
(1)
(2)
OFFICIAL USE ONLY
IJ F.I.R. CODE
L
mi
f
LAND,
,:,;;I y C L I R K'S
'.,:GNA*l ORE
APPROVED [] DISAPPROVED DATE
-503—o z415--`
STAFF ACTI
LREVERSE APPL. NO.: t
S 0 j
SIDE DATE el�zll!712i'
rAPPLICATION FOR:
NEW L IC. LICENSE
BUS. RENE YEAR F
OFHCIAL
LICENSE NUM
I . "I I
ri. ICLASSI YEARI LIC. EFFEC. DATE
CEIPT NO. DATE PAID
N ILA - NEW BUS.
LB RENEWAL
LC CHANGE
LID DELETE
REASG. LIC. NO. I SPcC
I RI NT " _. I
"N SP'EC. BOX
OR ISSUE OF
FEE PAID PENALTY PAID CORRECTED
'51 1
LICENSE W TH
TION.
LICENSE APPLICATION AND CHANGES
PLEASE PRINT CLEARLY
2. APPLICANT
AST NAME, FIRST.INITIAL OCIAL SECURITY NUMBER
_7
lie
F
DAST E OFMBIRTH PLACE OF BIRTH
T 0 a I T
0. 1 DAY IYEAR FE _lT Y T�_Ttl
Pi / 11q.317, IT101101191f NI/ A I N I I I I I at, 141
1 1 1.
HOME ADDRESS
BLDG. NUMBER
STREET
1 Ile ir. I I I I I I
APT. NO.
I I I I
CITY
1_�IP CODE I
I I I
3. BUSINESS IDENTIFICATION
NAME (FULL)
�BUSINESS
CiOj-ri'T' ifII0IplL+,qIx I I I I I I I I I 1 J 1 1-1-
NATURE OF BUSINESS (DRUG STORE, CPA, ETC)
-1
BUSINESS PHONE
�A
lq:� I(c
F_ WASH. STATE TAX NR. ANTICIPATED TYPE OF OCCUPANCY�
GISTRATIO JNR. EMPLOYEESI ORGAN. TYPE CAPACITY
AlL=g
ENTER APPLICABLE TYPES AND CAPACITY t
4. BUSINESS ADDRESS
LOG. UMBER
lb� 11\1
STREET
-7 Iq
-;+� I \N
LICENSE MAILING ADDRESS
BLDG, NUMBER
I [S'TREET.,A,,,
110si
I I I I
I I I I I
I I I
CITY
-a am) 113 D�sj Ata
11 1 1 1 1 1 1
1
STAT�
1 �1'1 M
ZIP CODE
ict, C, AIR P
/5. EMERGENCY NOTIFICATION (IN EVENT OF FIRE, BURGLARY, ETC.)
ST NAME, FIRST INITIAL AREA CODE TELEPHONE
apit, 1 11,51 k A, 4,
ST NAME, FIRST INITIAL AREA CODE TELEPHONE
(2) . 0
I I I A 91 c I
DS urrit,!AL U�t UNILT
1U. F. 1. R.
CODE
.OND. USff PERMIT LAND ILSE,
A L' A -.5
RE L
PUR A
ZONING
DATE
NOTICE:
No warranty of accuracy.
The information shown on the attached
map(s) was compiled for use by the City of
Edmonds, its Employees and Consultants.
The City of'Edmonds does not warrant the
accuracy of anything set for - th on these
map(s). Any person or entity -requesting a
copy should conduct an independent
inquiry regarding the information shown on
the map(s), including, but not limited to,
the location of any sewer stub shown. Such
sewer stubs may or may'not exist and may
or may not exist at the location shown.
Neither the City of Edmonds nor its
employees or officers, shall be liable for the
information given on this map(s), nor for
any one representation provided based
upon said map(s).
APPLICATION
The City of Edmonds for EASEMENT NO . ............................................
SIDE SEWER PERMIT
NEW CONSTRUCTION REPAIRS LID NO. � ----------------- ASMT. NO. ..........
/D
OWNER ...... CONTRACTOR . ...... PERMIT NO.
..........
JOB ADDRESS - ------ LEGAL DESCRIPTION: LOT NO . ................ :��
--- ------------------ BLOCK NO - ------------------------------------
qb
..................................................................................................................................................................
-1# A -
NAME OF ADDITION ...... R=FSCZ�CNe . ............................................................
Approved:
27
DATE................................ By ........ ).-"- --, �jjjyg
771
r,% ;R �, 7
TO
PE
"EM
4OP" MONDS SIDE Wi R.
''CE V�,,
MY, -rT
.01
IA
RIM
IRT
�IWATEWSEWMWOEPA XEN-t�**
'IT
for �slde-;sc��e
Cjlall' r,,,��sp�c�i�nli,.�,rtORE,,.,cpyeiingi.�any,,:,Poftibnt',of jhe,.,,const!�C!iop'..)�
Inspectl6n%will:�be prbvlded,',%,�ittiln',24:ffour�i aft&,'requst.-
L . NOV-sav, 'Sun. 4��hblljdW�' Inspections:'
A0DRESS!)k6Ck"0T('0F: . ........
............... ....................................................................... . ..... ......
Eitk-Y"!'EEGAML�,DESCttlpTICON-.* .................... 0J,
Pk0k
.................. ............ .........
A,
..............
................................................... ............... .................................................... ................................ :� .........
................................. 6W-Nkli, AN-6XbRASUh�bkK .................................... .. ...... .......... ................................ ..
7.:i ..... ...........
6T4iRACT-0R'V;M%ME5& ADDRESS ......................... 13,
U-M, C_;E F�, .. ... .
........................................................... . ... . . ................. .. ................................ .. ....
:160,61',hie on of w'side,sewer
Isslorilsi" ted'.. air onnecti 4.
% 4 7_
gi�an, ) ... ...... ............................................. -ci San alx�lsewer� `�l
acco�d�Ln4bbwlth,,Ci�j,'*i!,Edmonds, oedindnee
'o S;
N
'A.7E TION(jS11CALLED-�TO' TH�E: FOL13
OWING:,
VOTE! No.,�i--T�e,,o'wner'�;'of�-the�.p'�op�rty,"r�ak,. obtairi 7a ��,:Ii�--ensed:�si�e-�sewer,�p6ntriLetor,,'must �bp,,"eT:Plby,6d;4t6A'c�n.tru.
Permit to,�construct'sewer.'Insidb�property�line,�,,. t
�sld�*-sewerinl;str Ua a..,, Do- not cover any po tion of sewer.,be fore At -hasi`be6n'insj��cted.
ei re
r
�!,NOTE�No., 2��wlif �vor�: i;erfor��df,ln "city'- -of-way requlres� an -Inv . aslo n �of lugh , t '-of-Wa , Y. " P I btklrhble�from the CItyEn' offlc6:
gincer!s
3 aii� ju I li',i hformat ton �egarc!l ng, Ordinance 14.16;030.and.,Reguiation�; -io�ern
`NO.fb�No. —Obt
ing�.stftzse%ycr� en' ul,get'Plermit.—I. :-
NOTE,, ';sId�,sle�tei.,!iYf6si lftches��coverage j��,prop�ity lllne;�an& 12,itichi�-I'nsid�",�ro�'erty,.Iine;'--minithum,,gradei*of 2'%.. No,bendsjjin!ijrddV�:- .,j�
No:.A,T.�,�of
s�arper.thai�,,i/.-.�.%�.Illf�be'pei-initted
�NOTV-No:-,.5--Trench'cs,in'. street, must!,be� wisher'settleVand Isurface�.of.streev: restored' to.-origi n al', con d Mon. - Cont iaztors shall.�be,, esponsible, Jor lallurc,�due lo;'Irnproper'
work',which� may, d e velop,, wi t.h in, one year - of completlon�
an
'th �the do,any! worli.ion tfie.*Main- sewer,,.or;.Its appu ncesitex
'any.other �ork Js.provld�d *for.- in tw in:,
�ten a
'el Int6'the. wye..: 0'
scrt,the-,plpi i
'Date"
�DISAPPROVIED_E],�. Date: .......... 'BY .......... ....... ...... Date.: .............. . ..................... ..........
75EDI
APPRON ..................
.. .. ................ . ...................................... . .......... ....................................... ..................... ...............
j
................................................. .. . .... .......... ................ ........ ...... ........... ........ .............
......... ...........................................................
.......................................... ................
................................ ...... ..............................................
............. .....
-0
6 jilii6R �r-_&:,k�qhest For�,Ins'pe&ibn,'�.
bpte
s, MUST Be Si -Firm erf6rrh nstri�ction,.
.. .. I ... ......... dert.y. "t Ilation,.cbriitrudted�.undiar-�thisi,,pe�r-iii��,...
. ................................. . ereby` - if, .,,tliabthe*tsi ei:seWer ins a
�0.
. .... (Own
o[;Con cting FJrm-'-P�rfGrming':Const
�`Edhiond
'was;!nAall'e,d%Jma cordbLn %quYi.s.1V gove�nihj��Or�ffiaii, f ",t- ityL,of S.
f: ........ ........................ _4
Dat dl 11ii . , , - , 9 ". - - -
.........
'VY V
V 2
APPLICATION
for
"EASEMEN
'---The.'City of Edmonds �- �r� T NO.
-' . 4 1 ,
T - -------------- .......................
SIDE SEWER PERMI
NEW CONSTRUCTION REPAIRS LID NO . .................. . AS.MT. NO .......... r
C
OWNER ............. <�/"j ........... ONTRACTOR . .............. ----------- i t ....... PERMIT NO.
7 ON: LOT NO . .. ... BLOCK NO . ..... - -----------------------------
JOB ADDRESS -------- ..... ------ ?Y�CkEGAL DESCRIPTI
............. ............................ ................................................................................................................
..................
AME"I U, ........
OF ADDITION � ----- -- .. Y, ---- .... ... ......... : ..............................
ee
Approved:
DATE.............................................. By ....................... .......... .................
77
P:.PT. MEn, LIST A\/ fZ10
P 7 1
UT Pj.\'F!7,F
))-ff FILA;
rQR-T RkIE
)J
Strcct Pdpht-oF-Way Existin"
TZEOD
Access Easements F.xisting
M)
utilitv T'ascinclit Existin-
—T)
RF011
Lot Per Subdivision
P) at
Assessor Tlm)
Site Plan (Iccl,od for Accuracy
41 H'I
un
I
lhi(icrprcund 'v,irixx1 �cnd.
I. . I '( �.1 'i I fAv . e I k u::;:7 -
110 v *1 C "..7 Date
Fxistinr, 1.atcr Main
Water "ain Poc-,!ircd
1!vdnint "'iLze
n,,! ��r.hre Cndc,
P-Ltector "otcr Rc m, i i r e (1,
Cpmedibn fw_.1*)(�t7jj 61,
LA
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o I vlZ" I- cr�v�'T
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S(,;)Ii.c Tzm�. Dusj�,.n ,Nnproved Rite
Septic T��nll. PonviLt Pemvind Pemi t "0.,
Sallit"Iry Sc'we Avnil�ahilit�y !'ro i
1) 1 -x : i 11:1 'NO MIC "0.—
Sidu �)Cl,:Cr Av'-dja5ilit'�
S, u i -,*. t � i ry Connection Fee llcquircd
_—Pate-
-777=11
'Di tc�i C L; Ronuilc(I
.,X,.,
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Culvort N.:quirod Sj.-'e
0 L4 _Z�'
E-� Catc"I P"15;11 P10(mil, Indicate on '�itc Pl.an
Ilk- Bmc-'Ton in c,:wcdc
i-, ( 1,12,
e. i't.1 n r
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on Site Ill,
S()ij C,111(litiol-IS F1 GA-CA111d IC.',ItCr Field
Review b%, ivite
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ELEPHONE NUMBER
- 6 �_? 11 I'L_
3erty (Show Below or
FA_
IE NUMBER
NSE NUMBi
r
2--N'E W
RESIDENTIAL
GAS
LIN E
RADD
PALTER
NON-RESIDENTIAL
SIGN
RETAINING
WALL
FENCE
I— ___1 .1
DEMOLISH
EXCAVATE
OR FILL
ElREPAIR
PRE -MOVE
INSP.
swim
POOL
NUMBER OF STORIES
NUMBER OF
—
DWELLING
UNITS
NATURE OF WORK TO BE DONE
PROPOSED USE
z
0
PLOT PLAN (INDICATE BUILDING SETBACKS,
Ir ABUTTING STREETS)
W
0
LEGAL LOT —��
LOT AREA
SUBDIVISION NO.
STREET R/W
EXISTING STREET R/W FT. DEFICIENCY THIS PROPERTY
COMP. PLAN ST. R/W AS FT. C) FT.
REMARKS
CHECKED
BY.
Lu
STREET AND/OR UTILITY WORK
REQ'D. *YE:S NO
R/W PERMIT REQUIRED
YES No
UNDERGROUND
WIRING REQ'D. &YES NO
TYPE CONNECTION UYES IVERIFIED
SANITARY SEWER NO
B
SEPTIC SYSTEM 1:1 YES
APPV'D BY CITY ENG.
'1rN 0 KYA
J_PERMIT NUMBER
REMARKS
METER.SIZE
SAL
/_7
BUILDING STLY SIZE
-
REMARKS I
5s - ?P-ao L(_�mcl (Z-
SIGN AREA
AL� PROP . OSED
ENV. REVIEW
COMPLETE EXEMPT
�/
ADB NO.
-AILA-77
REMARKS
VARIANCE OR CU
PLANNING REVIEW BY
DATE
YARDS FRONT SIDE REA
RILOT COVERAGE
FIRE ZONE;,
iiO_
TYP!!:VONIRUIIIN
I
DE
co 0 PC- I I
ECIAL INSPECTOR AREA
REQUIRED .
11 YES 16 NO I
OCCUPANCY OCCUPANT
GROUP LOAD
I I: ]
PLAN CHECKED BY THIS SITE IS LOCATED IN THE CITY
OF EDIVIONDS.- LOCAL SALES TAX
SHOULD BE CODED 31.04.
REMARKS
qtjoi C)
PLAN CHECK
NO.
VALUATION
FEE
BUILDING
PLUMBING
HEAT ec GAS LINE
FENCE
SIGN
RETAINING WALL
SWIMMING POOL
Ap
Dr)
Pi
S t r c 0 t R
TTOT)
Access r-%'c,;ncnts Existin
-7
tin TTOI
Utility Eascinclit )"xis !I FT I
Lot Per Subdivision P1 at A-s-,,essor 1:ap
-7
)itc Pj.,�.n (Tccl.cd for Accuracy
!�cod.—
Fxi-tiii.(7 1*,',itcr !"Ain
7-17
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1-;,iter "ain Pc,(--�iircd 7 1 , J,)
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Filc
Sidc
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c:onnection Fee 11ccluircd
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Catdi P"15;11 Pc(ii-Ii reJ Indicate oil
Lr In ��vck
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oil Site Mmi
Son C."11clitiol, 'round !:,itci- Field 010.1c, -C,
Review by—
Aim)
F-'=
4BUILDING DEPARTMENT Applicant Fill
USE
ZONE C NUII�
Inside Heavy Lines
PERMIT APPLICATION
ADDRESS
� )_ 3
NAME (OR NAME OF BUSINESS)
_5'e"X1_fe.7-
LEGAL LOT
WYE
=s 0 NO
LOT AREA SUBDIVISION
NO.
W
MAILING ADDRESS
iz
3:
0
.2 3
0
STREET R/W
EXISTING STREET R/W FT. DEFICIENCY THIS PROPERTY
COMP. PLAN ST. R/W FT. FT.
CITY
1
ELEPHONE NUMBER
NAME
REMARKS Driveway slope not to exceed those
Z
indicated on Standard DrawinR #103.
m
W
W
ADDRESS
CHICKED By
W
U
M
<
CITY
I
ELEPHONE NUMBER
IT
STREET AND/OR UTILITY WORK
REQ'D. J#YES 11 NO
RED
12YES 0 NO
Z
W
NAME
UNDERGROUND
WIRING REQ'D. CyEs ONO
0
I-
U
Z
0
ADDRESS
TYPE CONNECTION MYES
SANITARY SEWER
0 NO
VERIFIED BY
CITY
TELEPHONE NUMBER
SEPTIC SYSTEM. YES
APPV'D BY CITY ENG.
EiNO
PERINIT NUMBER
INA
U
STAY LICENSE NUMBER
CITY LICENSE NUMBER
REMARKS
2- 2- 3 — 0 / - �, 2- p )1_11'
I
Z
2
Legal Description of Property (Show Below or Attach Four Copies)
MET YRIZE
BUILDING SUPPLY SIZE
W
P,44 7- e -V ARP601"I_
REMAPS t
im 5� - 12m
SIGN AREA
ENV. REVIEW
ADB NO.
-mu
W
0
ALLQ!�� PROPOSED
COMPLETE EXEMPT
-4,F-7
J
REMARKS
W
J
VARIANCE OR CU
PLANNING REVIEW BY
DATE
YARDS FRONT SIDE REA
RI LOT CO I VERAGE
GAS
2-'N E RESIDENTIAL LINE
NON-RESIDENTIALI SIGN
ADD
F
DEMOLISH RETAINING
1:1 1:1 1-1 WALL
ALTER EXCAVATE FENCE
1:1 OR FILL J_ X_FT)
REPAIR PRE -MOVE swim
1:1 INSP. POOL
FIRE ZONE
-Tr
TYPE OF CONSTRUCTION ICODE
, - Q
I _T
U13C- 19'73
spisem'C INSPECTOR AREA
RE QUIRED
0 YES NO
OCCUPANCY-r—
GROUP
_L
OCCUPANT
LOAD
LO,
,
PLAN CHECKED BY THIS SITE IS LOCATED IN THE CITY'.
OF EDMONDS. LOCAL SALES TAX %
SHOULD BE CODED 31.04.
REMARKS
-
z
W
NUMBER OF STORIES
NUMBER OF
DWELLING
UNITS
NATURE OF WORK TO BE DONE
W
0
PLAN CHECK
NO.
BUILDING
VALUATION
FEE
z
2
F.
CL
m
U
0
W
a
1'..
Z
W
I
0
J
W
>
PROPOSED USE
PLOT PLAN INDICATE 13UILDING SETBACKS,
ABUTTING STREETS)
11
PLUMBING
HEAT & GAS LINE
m
0
W
FENCE
AO
z
SIGN
RETAINING WALL
U
WE
SWIMMING POOL
MAI