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.-..'CITY of EDMONDS SS LICENSE APPLICATION
- .. I DATAII& LICENSE NO.
Civic Center * Edrnoncls� Washing!nl*
-1 City Clork Phone 775-2525 E' TYPE OF BUSINESS ANNUAL FEE AFTER FEB. 15
ro" f - FLE
CLASS YEAR LIC. EFFEC. DATE REASG. LIIC. NO. SPEC. C] (A) HOME OCCUPATION $15.00 $ 22.50
4STRUCTIONS: (B) BUSINESSWITH $20.00 $ 30.00
All items must be completed -RECEIPT NO. DATE PAI PRINTX' 1 TO 3 EMPLOYEES
6 IC
or application will not be ac- 131& 1 11 . IN SPEC, BOX 0 (C) BUSINESSWITH $22.00 $ 33.00
cepted. Uz7' d / A T, FOR ISSUE OF 4 TO 9 EMPLOYEES
Sign and return application FEE PAID , I PENALTY PAID CORRECTED Ej (D) BUSINESS WITH 10 EES $75.00 $112.50
/ I d : LICENSE WITH OR MORE EMPLOY
with fee. Renewals received I 'LC'ACTION.
after February 15 must pay .0 NEWAPPLICATION (LA)
penalty in addition to fee. 0 RENEWAL (LB)
NEW BUSINESSES AFTER 0 CHANGE (LC)
JULY 31, 1/2 FEE. (PLEASE MAKE ANY NECESSARY CHANGES) 0 DELETE (LD)
_D NAME OF FIRIVI-- BUSINESS PHONE71NO. OF EMPLOYEES
1L) P J 0 14 A N S EA /1 N T-1 Q_U r--- C L(---
MAILING ADDRESS NATURE OF BUSINESS
AN-T-1 Q \3 E_ _-N-L2 L-)
5- n �_ rL- 5- f / �-:; 11 Q (i I C_ t,
BUSINESS ADDRESS INDIVIDUAL PARTNERSHIP CORPORATION
_�_:3 7 M4, t�' rz- D [-I F�A__ (S) (P) (C)
OWNERS NAME HOME ADDRESS
DIAIUR J j0HAt-15rrj, ZA-1 7 17 PIL PA,_QG-eWoo0 -Ml�,jDe_
SO
-2,�� -37 QA'FF1_rL_ CIAL SECURITY NUMBER
HOME PHONE .5 2-+911-7S DATE OF BIRTH PL;ACE OF BIRTH
7 7 ? 0+-�I_ �9 _3' 5� - 3 74 2
EMERGENCY NOTIFICATION (1) NAME& TELEPHONE T)da,0:51, tJ / -7 2 o q- 7 -,-
(P LEASE LIST TWO) (2) NAME & TELEPHONE Od Lq :Z4:3 z 72-�
APPLICANT'S SIGNATI )RE
WASHINGTON STATE TAX NO. C 3 1 q I-) ! I � �,� , �,_,
DO NOT WRITE BELOW THIS LINE
STAFF REVIEW: FILL IN LAND USE CODE, UFIR NUMbERS, ZONING, ETC. CHECK APPROVAL OR DISAPPROVAL, DATE, AND
SIGN. IF DISAPPROVAL, PLEASE COMPLETE "COMMENT" SECTION. ROUTE TO NEXT DEPARTMENT ON LIST.
PLANNING DEPARTMENT DATE A LAND USE CODE ZONING CODE
'15 APPROVE 0 DISAPPROVE SIGNATURE
CONDITIONAL USE PERMIT
COMMENTS
BUILDING DEPARTMENT DATE
[�'APPROVE 0 DISAPPROVE
Building
El
Hotel/Motel
(L)
SIGNATURE
Permit
0
Apt. Bldg.
(A)
El 1
0
Office Bldg.
(0)
COMMENTS:
Occupancy
Group
0
0
Restaurant
Hosp/Nurs Home
(R)
(H)
CAPACITY: (NO. UNITS, APTS. OFFICES, SEATS, BEDS, STUDENTS)
0
School
(S)
FIRE DEPARTMENT DATE U. F. 1. R.
X APPROVE El DISAPPROVE SIGNATUR
COMMENTS:
z;I/
POLICE DEPARTMENT
DATE SIGNATURE
PkPPROVE 0. DISAPPROVE
COMMENTS:
PUBLIC WORKS DEPARTMENT
0 APPROVE 0 DISAPPROVE DATE SIGNATURE
COMMENTS:
PLEASE RETURN TO CITY CLERK