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660 13TH WAY SW
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CITY of EDMONDS BLISI LICENSE APPLICATION
Civic Center Edmonds, Washington 9802*, DATE LICENSE NO.
0 C�Mp%
City Clerk Phone 775-2525
IS I MEET FILE TYPEOFBUSINESS ANNUALIFEE AFTERFEB.1
INSTRUCTIONS:
• All items must be completed
or application will not be ac-
cepted.
• Sign and return application
with fee. Renewals received
after February 15 must pay
y 'ddi�f;
penalt in a i&K ff'fee,
qNEW BUSINESSES AFTEF3)
ULY 31, 1/2 FEE. -_,------
NAME OF FIRM
h
, I I I , I
I I I
I
I E] (B)BUSINESSWITH
$20.00 0 0
RECEIPT
NO.
DATE PAID
1 TO 3 EMPLOYEES
PRINT'X'
__+K SPEC. BOX
E] (C) BUSINESSWITH
A�3
$22.00 .00
17
FOR ISSUE OF
4 TO 9 EMPLOYEES
FEE PAID
FIENALTY, PAID
CORRECTED
El (D) BUSINESS WITH 10
$75.00 $112.5
f—A
I Q1 '7L'!91UI
I I I I
LICENSE WITH
'LC'ACTION.
OR MORE EMPLOYEES
W APPLICATION (LA)
0 - RENEWAL
R E C E I VfD
0 CHANGE
(LC)
(PLEASE MAKE ANY NECESSARY CHANGES) 0 DELETE
BUSINESS PHONE
NO
F EMPLOYEES
viIAILING ADDRESS 11 OF
e2 /3 fl-
/_� ( A) HOME OCCUPATION $15.00 $ 22.50
2a - ezd 7/ JJ��I�j DEPT.
NATURE OF BU'SINESS /,
BUSINES5_AQDRESS INDIVIDUAL PARTNERSHIP CORPORATION
0/0, F/,: - �), E22r(s) (P) (C)
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—W __r4y xs
OWNERS NAME HOME ADDRESS
6��42 13 "� -
HOMEPHONE DATE OF BIRTH PLACE OF BIR , I ;URITY NUMBER
721 7 - 47- T;L
EMERGENCY NOTIFICATION (1) NAME& TELEPHONE n�4" 141,
(PLEASE LIST TWO) (2) NAME & TELEPHONE
WASHINGTON STATE TAX NO. APPLICANT'S SIGNATURE
DO NOT WRITE BELOW THIS LINE
STAFF REVIEW: FILL IN LAND USE CODE, LIFIR 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 LAND USE CODE ZONING CODE
X APPROVE P DISAPPROVE
SIGNATURE
CONDITIONAL USE PERMIT
COMMENTS =1 E= E2
13U!�DING DEPARTMENT DATE Building 0 Hotel/Motel (L)
L-l"APPROVE 0 DISAPPROVE SIGNATURE Permit 0 Apt. Bldg. (A)
0 Office Bldg. (0)
COMMENTS: Occupancy 0 Restaurant (R)
Group 0 Hosp/Nurs Home (H)
CAPACITY: (NO. UNITS, APTS. OFFICES, SEATS, BEDS, STUDENTS) 0 School (S)
FIRE DEPARTMENT DATE U. F. 1. R.
/XAPPROVE 0 DISAPPROVE SIGNATURE
COMMENTS:
POL!�',E- DEPARTMENT
W,-APPROVE 0 DISAPPROVE DATE 'Ila 0_;�-�GNATU RE
COMMENTS:
PIJAIC WORKS DEPARTMENT
E� APPROVE El DISAPPROVE DATE SIGNATURE
COMMENTS:
131 C A C C 0 C-r 1 10 K I -rf-A t� 1 -rN/ t- i r- m tz
The City of Edmonds STFC-D� EF-T
APPLICATION
for
CARD No . ......................................
SIDE SEWER PERYaT
OUTSIDE INSIDE REPAIRS
EASEMENT No . ......................................
....
OWNER ----- ........... ......... ........ 40;�- .................
CONTRACTOR ...... Y eQ
.... oe ..........................................
Do p
<�. PERMIT No.cZD5
HOUSE No . ...... ....................... ------- /.'IT ....... W-14-Y ................... ........
STREET
AVENUE LOT No . ............ --777- .... 6 .........................................
BLOCK No . ...............................................
NAME ADD. .. .. i�lhf�t .........
............................
10
Date /
BACKFILL WORK ORDER ISSUED ................................... DEPOSIT, $.-. ......
SEWER WORK ORDER ISSUED ..........................................
---- By ... /A
APPROVED
a0m 9-9 19sa