611 MAIN ST STE E��f3. &0n
CITY OF EDMONDS
--"OUSINESS LICENSE APPLICATION- COMMERCIAL
FEE: $125-00
CITY CLERICS OFFICE, BUSINESS'LICENSE DIVISION
P�"111121 5' AVENUE NORTH, EDMONDS, WA 98020 PHONE: 425.775.2625
OFFICE USE ONLY
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Customer#
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Year
1,.2A 13
I ClassT__§H�D
1 B
1
Date Paid
�5 - -7 -13
I TR#
F2 J6 _0�0'
Fee Paid
0 0
I Mailed
1
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INSTRUCTIONS: Please corriplete the application in full and attach the required floor plan. Middle initial or narne 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 Edmondi required
If"business closes.
BUSINESS NAME
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Se�-_u C�;g�
LL_�C_
BUSINESS ADDRESS
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9 g-o'go
Street
Suite No. Zip Code
MAILING ADDRESS
(o ffl &'%YA S +
FXw\e) r\ J:5 W A -
Street or PO Box
Suite No.
City, State and Zip C6de
BUSINESS PHONE NO. -2D ( g- I —k/,g < /,o .7- -,X1 33
o 50 (ijj�AS:TATE TAX ID NO. (�UBI NO.)
BUSINESS E-MAIL !�V-ef
1,1 +e
-BUSINESS WEBSITE 00f J.,
PROPERTYOWNER
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Name
Phone Number
EMERGENCY NOTIFICATION (For Premise Access In Emergency):
7 ZS e 5,*e4
Last Name
First Name
MI Phone No. '
0 r.. - -rc r r 3 ;7- t
-) � ee_��
Last Name First Namia Mi Phone No.
NATURE OF BUSINESS MjL(-r-1'o,,4e A F7j7_ vy i I' _n,)ey-e,
NUMBER OF EMPLOYEES SQUAR FOOTAGE OF BUSINESS SPACE
TYPE OF BUSINESS - PLEASE CHECK -THE- APPROPRIATE CATEGORY:
0 CONSTRUCTIO . N . 6 FINANCE, INSURANCE, REAL ESTATE o LANDSCAPE. HORTICULTURAL 0 MANUFACTURING 0 NON-PROFIT
ORETAIL OSECONDHANDQEALER FSERVIQES OWHOLESALE OOTHER
AMUSEMENT DEVICES -ON PREMISES? CjYES qNO IF YES. TOTAL NUMBER
LIQUOR SOLD ON PREMISES?: 0 YES PNO.� G . AMBLING? 0 YES JNNO CIGARETTES SOLD -ON PREMISES? OYES ONO
FJLAMMABLE OR HAZARDOUS MATERIALS USED "OR STORED?: 0 YES P NO IF YES, PLEASE PROVIDE LIST OF MATERIALS AND QUANTITIES:
PROPOSED OPENING DAY -OF BUSINESS ff\JO-1-i BUSINESS HOURS I —
DAYS OPEN 0 SUNDAY XMONDAY XVTUESDAY eWEDNESDAY e-rHURSDAY -FRIDAY - 0 SATURDAY
PARKJNG SPACES ON SITE: TOTAL ACCESSIBLE FOR PERSONS WITH DISABILITIES. �e_S
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? 0 YES 0 NO
PREVIOUS BUSINESS 'USE AT THIS ADDRESS XIL.�9* De,�>f,nncf(
SOLE PROPRIETORSHIP
NAME (_�,Y70fll _F(f rc,-1 6
Last First MI
ADDRESS Ze'10 Af / 7�
Street Apt. No., Unit No. City. Slate 6nd 7ip Code
HOME PHONE NO. DOL NO. (DRIVERS LICENSE NO.) OR OTHER ID NO. -CENTA T
DATE F BIRTH CITY AND STATE OF BIRTH'3e0_'f+fC (I -) 74 -7- COUNTRY OF BIRTH 14-
PARTNERSHIP - PARTNER I
NAME
Last First MI
ADDRESS
Street Apt. No.. Unit No. City, State and Zp Code
HOME PHONE NO.(---- DOL NO. (DRIVERS LICENSE NO.) OR OTHER ID NO.
DATE OF BIRTH _-CITY AND STATE OF BIRTH COUNTRY OF BIRTH
PARTNERSHIP - PARTNER 2
NAME
Last Tir5t MI
ADDRESS
street Apt. No., Unit No. City, State and Zip Code
HOME PHONE NO.(
DOL NO. (DRIVERS LICENSE NO.) OR OTHER'lb No.
DATE OF BIRTH CITY AND STATE OF BIRTH --COUNTRY OF BIRTH
NAME OF CORPORATION FEDERAL TAX ID NO.
CORP.ADDRESS
Street Skoite.. Apf' PHONE NO.(
_Unft.No. f"ity.-Steate and Z.1p Code
CORPORATE OFFICERS:
Last Name First Name
MI Title Date ot Birth DOL No. (Drivers License No.) or Other ID No.
LOCAL CONTACT I
Last Name First Name MI Title P NO.
DOL No. (Drivers Lic� No.) or Other ID No.
APPLICANT- 7 7 �rr- tf:,.
Name.- P . dntpd Sig we�
�Sii_9_9(* J Tide
BUILDING:PEPT-, OAPPROVE ODISAPPROVE DATE SIGNATURE.
OCCUPANTLOAD'. BUILDING PERMIT OCCUPANCY GROUP
COMMENTS
FIRE DEPT. 'D APPROVE 0 DISAPPROVE DATE
SIGNATURE q.
U.F.I.R.-
COMMENTS
POLICE DEPT. D-APPROVE 0 DISAPPROVE DATE
-SIGNATURE
COMME
�36,
Serving griel;, Ednionds V.,
,SNOHOMI
Mountlake Terraceand
DISFIR www.FireDistrictl.org
Rl the ToWn of Woodway
LOCATION: 611 Main St.
\j BUSINESS NAME:
MAILING 611 Main St Suite E
ADDRESS: Edmonds
BUSINESS OWNER: rit
EMERGENCY-1:
Ga%pbekl ow
KEY ACCESS-2:
PERSON CONTACTED:
NAME OF INSPECTOR:
FIRE
SYSTEMS:
C.
12425 Meridian Ave S
Everett, WA 98208
Phone (425) 551-1200
Fax (425) 551-1272
E
PHONE: 4257785080
98020
V,— HOME PHONE: 4257763937
HOME PHONE: 4257756446
HOME PHONE: 4253612343
FIRE PREVENTION
INSPECTION REPORT
0 EDMONDS
El BRIER
OWOODWAY
[I MOUNTLAKE TERRACE
0 UNINCORPORATED
I'- FREQUENCY
STATION & SHIFT"�
731
17 B
I
SCHEDULED
DATE DUE 1` 07101111
UFIR � 591
7203
CURRENT
CITY YES NO
BUSINESS F-1
LICENSE
INITIAL INSPECTION DATE
—7/9// /
FE I
A14NIUZ
HAZARDS FOUND AND LOCATIONS / COMMON]WIONS
L
2
2
3
3
4
4
5
5
6 444- 4
6
p".
7
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT aO DAY x
lst RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTED TO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
1
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DA E:
DATE:
3
VIOLATIONS
1 5
VIOLATIONS
1 5
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2
6
2
6
DATE:
CODE
SECTION:_
3
7
7
RETURN RECEIPT
RECEIVED
6
14
18
4 j
8
DATE:
DISPOSITION:
7
LErrER NEEDED [3 YES El NO
LETTER NEEDED C] YES NO
8
FIRE DEPARTMENT'COPY