23830 HWY 99 STE 119�L
............. . ---
Z3,930 qMWWA-j '9? S",,
It - ),q
CITY OF EDMONDS
4:� Nil
Tu Budding
BU COMMERCIAL f-
SINESS LICENSE APPLICATION - Engineering
FEE: $125.00 t:-_ Fire
L Planning
T CITY CLERK'S OFFICE. BUSINESS LICENSE DIVISION Poke,
1215 'AVENUE NORTH . EDMONDS, WA 98020 PHONE 425.775,2525
OFFICE USE ONLY
INSTRUCTIONS: Please complete the application In full and attach the required floor plan. Middle Initial or name required of all parties concerned. If no
middle name, please indicate by writing NMN. Sign and return application with fee. Please advise of any change In status. New license required If
business changes location or owrvemhtp. Notification to City of Edmonds required If business closes. License "piros December 31" each year. Renewal
must be submitted arior to January 31" to avoid late fees.
BUSINESS
BUSINESS
MAILING
FrA
-T 0
tu)q /`,9/33 /
StReel or PO Box A Suite # City, Stato,'hp Code
#1 11 1/
BUSINESS PHONrf WA STATE TAX 10 d (UBI) 0 q I q q
BUSINESS E-MAIL A '*Jldil %.A0\oi)- C-OW) BUSINESS WEBSITE
,*-,j
BUSINESS OWNER I MA IN CONTACT__D (I
,10 713-mq/
Name Phone Number
EMERGENCY NOT FICATION (For Premise Acoe3s in flerge-yY
M (ITO I I; *Z- Kom .9. -1 q
MI
Last Name F
NATURE OF BUSINESS (Provide a Delefled Description of
SPACE ALTERATIONS TO BE MADE�-YES_NO,>� DESCRIPTION
PREVIOUS BUSINESS AT THIS A DRESS
NUMBER OF EMPLOYEES 34 SQUARE FOOTAGE OF
'TYPE OF BUSINESS - PLEASE CHECK APPROPRIATE CATEGORY;
r- CONSTRUCTION
I- FINANCE, INSURANCE. REAL ESTATE
r LANDSCAPE, HORTICULTURAL
I MANUFACTURING
r NON-PROFIT
7 RETAIL
r. SECONDHAND DEALER
E: SERVICES
r- WHOLESALE
;W OTHER
V
AMUSEMENT DEVICES ON PREMISES? YES- __ --NO _�011` YES. TOTAL NUMBER LIQUOR SOLD ON PREMISES? YES� NO
GAMBLING? YES— NCL� CIGARETTES SOLE) ON PREMISES? YES NO—)&
FLAMMABLE OR HAZARDOUS MATERIALS USED OR STORED? YES N0__$Q IF YES. PLEASE PROVIDE A LIST OF MATERIALS AND QUANTITIES:
PARKING SPACES ON SITE: TOTALSPACES—_ ACCESSIBLE SPACES FOR HANDICAP PARKING_
W,
ES THE BUSINESS CON i AIN AN FNTRANGE ACCESSiBLE TO PERSONS14FIH Di BiLiTIES? YESe-% mu_
APPLICANT
NAME
Name
TITLE
Applications may be mailed In with a check, brought In person, faxed to 425-771-e266 or emalleid to business-litensegedmondswa.gov
with a valid phone number. we will call you for a Visa or MasterCard payment.
0 K, 1 /9 9 / / (,�,
e
j
s6—LE VRNP -0—ORSHIP
NAME___
LAST FIRST MIDDLE INITIAL
ADDRESS
STREET SUITEIAPTIUNIT# CITYISTATFJZIP CODE
HOME PHONE(--- DRIVERS LICENSE OR ID 6 & STATE
DATE OF BIRTH ----------PITYISTATE OF BIRTH —COUNTRY OF BIRTH
PARTNERSHIP - PARTNER I
NAME__
LAST
FIRST
MIDDLE INITIAL
ADDRESS
STREET
SUITEIAPTIUNIT A
CITYWATEWPCOor:
HOME PHONE(
DRIVERS LICENSE OR ID # 8 STATE
DATE OF WIRTH
CITYISTATE OF BIRTH --COUNTRY OF BIR
PARTNERSHIP - PARTNER 2
NAME
LAST
FIRST
MIDDLE INITIAL
ADDRESS
STREET
SUITEJAPT(UNIT9
CrryisTATEop CODE
HOME PHONE(
RIVER'S LICENSE OR ID # & STATE
I DATE OF BIRTH
CITYfSTATE OF BIRTH -COUNTRYOFOIRTH
NAME OFCORPORATION.. Olu-1-k
cl ly)
RATION/ LLC or PLLC FEDERALTAXION �)09
CA=` 141-� - a�
CORRADDRESS at m
Lowl`-'�t
BqLas- 5pdL IdAffi'5
Street
Suile�A-pl Unitilt State and Zip Code
Phone Numbir
CORPORATE OMCERS:
L981 qarrt,�
Fusl Norild
T tle Damola 2'-
A., I"
Ddeoes Oth 10#1S
�.2 Mo C>IJ
LOCAL CONTACT!--�6
Is —
Last Namv
F iekarne
MI Titile Daleafffirlh.
Dnvefo brenso or Olhar IDO /State
Phone Number
CITY USE ONLY'
BUILDING DEPT,
APPROVE
DISAPPROVE DATE
SIGNATURE
OCCUPANT LOAD
SUILDINGPERMIT
—OCCUPANCYGROUP
COMMENTS
ENGINEERING
M APPROVE
DISAPPROVE DATE
SIGNATURE_
FIRE DEPT
ED APPROVE
C3 DISAPPROVE DATE
SIGNATURE
U.F I R
COMMENTS
PLANNING DEPT
APPROVE
[—I DISAPPROVE DATE
SIGNATURE—
ZON ING CODE—
—
COND ITIONAL USE PERMIT
COMMENTS
POLICE DEPT APPROVE = DISAPPROVE DATE, SIGNATURE
COMMENTS
61,