1256 8TH AVE S11111111111111
14776
1256 8TH AVE S
ram'
0 "' C:'
G � �✓ /l I
;1TY /
="=�_• CITY Of EDMONDS
BUS ILE
tl A
ION
L
J z z Civic Center • Edmonds, Washington 980
City clerk . Phone 775-2525
dSTRUCTIONS:
CLA
YEAR ;LIC.
EFFEG
DATE JREASG.
LIC. NO.
SPEC.
All items must be completed
or application will not be aC
RECEIPT NO..
DATE
PAID
pRINT'X'
Cepted.
IN SPEC. BOX
FOR ISSUE OF
Sign n and return application
FEE PAID
ENA[
AI
I
CORRECTED
LICENSE WITH
with fee. Renewals received
' I I
'LC' ACTION.
after February 15 must pay
penalty in addition to fee.
NEW BUSINESSES AFTER
DATjjP_ LICENSE NO.
ANNUAL FEES
PENALTY AFTER FEB. 15
❑ HOME OCCUPATION
$10.00 (A)
ADDITIONAL $5.00 ❑ ,
❑ SMALL BUSINESS
$15.00 (B)
ADDITIONAL $7.50 ❑
❑ Business with 10 or
more employees
ADDITIONAL $25.00 ❑
$50.00 (C)
NEW APPLICATION (LA)
❑ RENEWAL
(LB)
❑ CHANGE
(LC)
JULY 31, 1/2 FEE. (PLEASE MAKE ANY NECESSARY CHANGES) ❑ DELETE (LD)
NAME OF FIRM I BUSINESS PHONE
NO. OF EMPLOYEES
//AILING ADDRESS ,�-�
NATURE OF BUSINESS
BUSINESS ADDRESS •:
INDIVIDUAL PARTNERSHIP
CORPORATION
_
l...../
EM (S) 0 (P)
O S NA E
�2 T—�2/�'
HOME ADDRESS
f
11.3 —,V-189 , cK4rYi
HOM E O_-N � .7
DA /OA IRT)i/
l9/ .�
PLACE OF�I" /'ft
SOCIAL SECURITY NUMBER
EMERGENCY NOTIFICATION / (1' NAME & TELEPHONE CJ - T ; /Y) Z--» 005
(PLEASE LIST TWO) (2) NAME & TELEPHONE ^ - Z • - ''fit
WASHINGTON STATE TAX
APPLICANT'S SIGNATURE
DO NOT WRITE BELOW THIS LINE /c ( na �b ll�7�,i11; ti
STAFF REVIEW: FILL IN LAND USE CODE, UFIR NUMBERS, ZONING, ETC. CHEEK APPROVAL OR
DISAPPROVAL, DATE, AND SIGN. IF DISAPPROVAL, PLEASE COMPLETE "COMMENT"
SECTION. ROUTE TO NEXT DEPARTMENT ON LIST.
PLANNING DEPARTMENT
Q�� ��
DATE
LAND USE CODE
ZONING CODE
!® APPROVE ❑ DISAPPROVE
SIGNATURE
CONDITIONAL
USE PERMIT
COMMENTS
E
m
BUILDING DEPARTMENT
' /5 -81
�PPROVE ❑ DISAPPROVE
DATE
��
''' ��
Buildin g ❑
Permit
Hotel/Motel (L)
SIGNATURE
❑
Apt. Bldg. (A)
®❑ Office Bldg. (0)
COMMENTS: Occupancy ❑ Restaurant (R)
Group ❑ Hosp/Nuys Home (H)
CAPACITY: (NO. UNITS, APTS., OFFICES, SEATS, BEDS, STUDENTS) ❑ School (S)
FIRE DEPARTMENT DATE - _ �/ U.F.I.R.
Q<APPROVE ❑ DISAPPROVE SIGNATURE
COMMENTS:
PO6105DEPARTMENT �( V_7; f� -7
APPROVE ❑ DISAPPROVE i DATE _ SIGNATURE ��9 l
COMMENTS:
4
P%LIC WORKS DEPARTMENT
APPROVE ❑ DISAPPROVE DATE SIGNATURES•:
COMMENTS:
PLEASE RETURN TO CITY CLERK