101 MAIN ST STE A_Redacted/61 MAxN S S; �}
°i ur EDMONDS
,4, BUSINESS LICENSE APPLICATION — COMMERCIAL
FEE: $125.00
CITY CLERK'S,OFFICE, BUSINESS LICENSE DIVISION
[� 121 5TH AVENUE NORTH, EDMONDS, WA 98020 PHONE 425.775.2525
❑
Building
❑
Engineering
❑
Fire
❑
Planning
❑
Police
OFFICE USE ONLY
BL#
Customer #
33o1a
SIC
►2
Year
aor S
pass
SREB-
o
I D tePaid
I TR#
Fee
I Mailed
I Deleted
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 ownership. Notification to City of Edmonds required If business closes. License expires December 315` each year. Renewal
must be submitted prior to Ja ary 31"'to a4old late fees. ` /n
BUSINESS NAME 0 l I �� eA I t vx C, J 190 " waf ` f U �(�fi u_ C /
BUSINESS ADDRESS ` O ( 1 Y lw VA Jli— Sic .
Stre�jet Suite #
MAILING ADDRESS �� D' • ' ��
Street or PO Box # Suite #
BUSINESS PHONE �or!, o WA STATE TAX ID # (USI) O
BUSINESS E-MAIL C BUSINESS WEBSfTEa
BUSINESS OWNER I MAIN CONTACT W O VIL
ot
PRQPERTY OWNER el
ZI
QVN Vr_-('k K2b W&TwnA
Name t 1 J.
EMERGENCY NOTIFICATION (For Premise Access In Emergency):
ChetyJ omT
Last Name ,/ _ FI t Name) MI
QQ
Last Name �i Fi'V Name MI
NATURE OF BUSINESS (Provide a Detailed Description of Business Activities, Products & Sep
SPACE ALTERATIONS TO BE MADE: YES_NO-K
PREVIOUS BUSINESS AT THIS ADDRESS_
NUMBER OFEMPLOYEES—
S
SQUARE FOOTAGE OF BUSINESS
TYPE OF BUSINESS - PLEASE CHECK APPROPRIATE CATEGORY:
❑ CONSTRUCTION
❑ FINANCE, INSURANCE, REAL ESTATE
❑ LANDSCAPE, HORTICULTURAL
❑ MANUFACTURING
❑ NON-PROFIT
❑ RETAIL
❑ SECONDHAND DEALER
❑ SERVICES
❑ WHOLESALE
u
e, OTHER
Phone
Oaa
City, State, Zip Code
Wn 9k00'\-0_)
City, State, Zip Code
LO, ✓
Phone Number
(ix,L 62-1' i k 3�
Phone Number
PROPOSED OPENING DATE: -1 1 --y ty
BUSINESS HOURS: -� c(m
DAYS OPEN:
SUNDAY
R/WEDNESDAY
Df MONDAY.
THURSDAY
p,TUESDAY
[/FRIDAY
XSATURDAY
AMUSEMENT DEVICES ON PREMISES? YES NO X IF YES, TOTAL NUMBER LIQUOR SOLD ON PREMISES? YES NO
GAMBLING? YES_ NO-)L CIGAR ETTES SOLD ON PREMISES? YES NO
FLAMMABLE OR HAZARDOUS MATERIALS USED OR STORED? YES NO. X IF YES, PLEASE PROVIDE A LIST OF MATERIALS AND QUANTITIES:
PARKING SPACES ON SITE: TOTAL SPACES 8 ACCESSIBLE SPACES FOR HANDICAP PARKING 9 Z
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? YES NO
APPLICANT N. aa,
NAME
Print. j. Signature
TITLE DATE
s13v'-" Oq C-�
M
er
SOLE PROPRIETORSHIP
NAME
LAST FIRST MIDDLE INITIAL
ADDRESS
STREET SUITE/APT/UNIT# CITY/STATE/ZIPCODE
HOME PHONE( ) DRIVERS LICENSE OR ID # & STATE
DATE OF BIRTH CITY/STATE OF BIRTH COUNTRY OF BIRTH
PARTNERSHIP — PARTNER 1
NAME
LAST
FIRST
MIDDLE INITIAL
ADDRESS
STREET
SUITE/APT/UNIT #
CITY/STATE/ZIP CODE
HOME PHONE(
I
DRIVERS LICENSE OR ID # & STATE
DATE OF BIRTH
CITY/STATE OF BIRTH COUNTRY OF BIRTH
PARTNERSHIP - PARTNER 2
NAME
LAST
FIRST
MIDDLE INITIAL
ADDRESS
STREET
SUITE/APT/UNIT #
CIIYISTATE/ZIP CODE
HOME PHONE(
1
DRIVER'S LICENSE OR ID # & STATE
DATE OF BIRTH
CITY/STATE OF BIRTH
COUNTRY OF BIRTH
O
1
N ti Sty,
EY
NI LLLCorPL
Cd a YUW W, tDERALTAXID#Ex
7�
NAME OFCORPORATION
.INCORPORATI
�t�N o��Lq,7SI�r�
15
� 3/ ✓
CORPADDRESS
�A+�� (��
Street
Suite, Apt. Unit # City. State and Zip Code
Phone Number
CORPORATE OFFICERS:
Last Name
First
MI , f2rTlle`
Q
v
ice �I
W �N
cq
LOCALCONTACT 1
MI Title DateotBft
c�� z t 33J
Driver's I ee or Other 00 / State
Phase Number
CITY USE ONLY:
BUILDING DEPT
OCCUPANTLOA
APPROVE 0 DISAPPROVE DATE SIGNATURE
BUILDING PERMIT
OCCUPANCY GROUP
Comm
ENGINEERING APPROVE DISAPPROVE DATE SIGNATURE
FIRE DEPT. APPROVE DISAPPROVE DATE SIGNATURE
U.F.I.R.
COMMENTS
PLANNING DEPT. Q APPROVE Q DISAPPROVE DATE SIGNATURE
ZONING CODE CONDITIONAL USE PERMIT
COMMENTS
POLICE DEPT, 0 APPROVE DISAPPROVE DATE SIGNATURE
COMMENTS
t ��,
d�
i
Set�,r\a,
Mtn
SNOHOMISH CO. ;i.• �'erving':Br1aer, Edmonds, an,:a
FIREMountlake Terrace
DISTRO, www.FireDistrictl.org
FIRE PREVENTION
12425 Meridian'Ave.S
INSPECTION REPORT
Everett, WA 98208
' ❑ EDMONDS
;.i .❑'BRIER
Phone(425) 551-1200
❑ MOUNTLAKE TERRACE
`
Fax (425) 551-1272
•❑'UNINCORPORATED
LOCATION: 101., Main Street Suite A 98020
BUSINESS NAME: Waterfront Coffee CO. PHONE: g25&Q
MAILING
ADDRESS: 101 Main Street, Suite A,;-Edrn;ond' , WA 98020
BUSINESS OWNER:��'
EMERGENCY-1: BAW_&,�
KEY ACCESS-2:
EMAIL: GrY..I►J D C7II0 aoad CVwk
S
PERSON CONTACTED:
NAME OF INSPECTOR:.„
FIRE SYSTEMS: FE 5/13
i
Dste3Last Serviced -
FREQUENCY STATION &rSHIFT
2015 17-C
SCHEDULED
DATE DUE ► Oct 2015
UFIR ► 513 202
HOME PHONE;t>'6 • /_�
HOME PHONE: 42.547R2q-@6
CURRENT
HOME PHONE:
�U(o38.350SJ
CITY YES NO
BUSINESS
LICENSE
INITIAL INSPECTION DATE
HAZARDS ND AN� TION MMUN�
IZ3 '
2 _ _—
_
2
3
3. ..
,L
4
4
4
5.____.__... _-'- -
_ _._ _
6
6
7
7.
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1st RE -INSPECTION
2nd RE -INSPECTION
EXTENSION
FINAL RE -INSPECTION
VIOLATIONS";
DATE DUE:
DATE DUE:
GRANTED TO:
DATE DUE:
CITED:
PERSON
PERSON
PERSON
CONTACTED:
CONTACTED:
-
CONTACTED:
INSPECTOR:
INSPECTOR:
INSPECTOR:
2 .r
DATE:
DATE:
DATE:
k' �- "
3
VIOLA
10'law
VIOLATIONS; -
�'
PRE-CITSENT
CITATION ISSUED
1
5
1 5
a
LETTER
NUMBER:
4
.__
CODE
S�—
�`
V
2
6'—
2
6
DATE:
,SECTION:
RETURN RECEIPT
3
y7
3
7
RECEIVED
4•'' /e1 8 f
4�r—.. ;:
,8;''�c
r
DATE
r�
DISPOSITION:
P LETTER NEEDED❑ YES �❑ NO
LETTER NEED�E,D •❑ 'iY Sti ❑ NO
*'•�
+ • F
:''`�
g
, ,,
SNOHOMISH CC
FIRE
DIST
II LOCATION:
• BUSINESS NAME:
MAILING
ADDRESS:
BUSINESS OWNER:
EMERGENCY-1:
KEY ACCESS-2:
EMAIL:
r
PERSON CONTACTED:
NAME OF INSPECTOR:
Serving Brief; Edmonds, and
Mountlake Terrace,
wivw FireDistrictl. org
101 Main Street Suite A 98020
Waterfront Coffee Co.
101 Main Street, Suite A, Edmonds, WA 98020
12425 Meridian Ave S
Everett, WA 98208
Phone (425) 551-1200
Fax (425) 551-1272
PHONE: 42567014
HOME PHONE:
BalaS, Steve HOME PHONE:
HOME PHONE:
i FIRE SYSTEMS:
42567227
FIRE PREVENTION
INSPECTION REPORT
❑ EDMONDS
❑ BRIER
❑ MOUNTLAKE TERRACE
❑ UNINCORPORATED
CURRENT
CITY Y S NO
BUSINESS
LICENSE
INITIAL INSP[CT ON DATE
HAZARDS FOUND AND L 9TIONS / COMMUNIC TIONS
1
h4A1
2
2
3
3
4
4
5
5
6
6
7
\
, i
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1
1st 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:
INSPECTOR:
INSPECTOR:
f
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
1 5
VIOLATIONS
1 'S�•
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2
6
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED
6
4
8
4
8
DATE:
DISPOSITION:
7
LETTER NEEDED ❑ YES ❑ NO
LETTER NEEDED ❑ YES ❑ NO
8
FIRE DEPARTMENT COPY
FIRE PREVENTION
Serving Brier, Edmonds 12425 Meridian Ave S INSPECTION REPORT
SNOHOMISH CO. ❑ EDMONDS
FIRE 'Moiihtlake•Terrace,and Everett, WA''98208 ❑BRIER
the Town of Woodway Phone (425) 551-1200 ❑ WOODWAY
DI'Or"R T ❑ UNINCORPORATED
TERRACE
wwwFireDistrictl.org Fax (425) 551-1272 ❑UNINCORPORATED
r
FREQUENCY STATION & SHIFT
LOCATION: 101 Main Street A '365 17 d
SCHEDULED
BUSINNESS NAME: Watef1Tont Coffee CID. PHONE: 42567014®0 DATE DUE ► 10/01/11
r MAILING 101 Mein St Suite A UFIR ► 513 1[202
ADDRESS: Edmonds 98020 ; r
BUSINESS OWNER: 13$ia$, Steve CT V IC ��Q, HOME PHONE: 425M6-- ACTIVE
HOME PHONE: EMERGENCY-1:-Pederseft;'P8t -� I
CURRENT
KEY ACCESS-2: �Ge#-4244P64M HOME PHONE: CITY YES NO
BUSINESS
LICENSE
PERSON CONTACTED: i CeJG(, G INITIAL INSPECTION DATE
NAME OF INSPECTOR: p C) ? r (
FIRE r" FE .5-1-1
SYSTEMS:' � ANNUAL
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS—
1
2
2
3
3
4
4
5
5
6
6
7
,� +�
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1st RE -INSPECTION
DATE DUE:
t
i
-•
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:
DATE:
DATE:
3 1
VIOLATIONS
1 5
VIOLATIONS
1 5
PRE -CITATION
LETTER SENT
'CITATION ISSUED
"NUMBER:
a
2
6
2
6
DATE:
CODE'
SECTION:.
5
3
7
3
7
RETURN RECEIPT.
RECEIVED.:;;_ ;'
'
6
4
18
4
6
DATE:
DISPOSITION:
LETTER NEEDED ❑ YES ❑ NO
LETTER NEEDED ❑ YES ❑ NO
` t
8
FIRE DEPARTMENT,COPY
CITY OF EDMONDS
Ij - 121 5TM AVENUE N. • EDMONDS, WASHINGTON 98020 • (425) 771-0215
FIRE DEPARTMENT
0
LOCATION: 101 Main Street
I.,
BUSINESS NAME: Waterfront Coffee Co.
MAILING 1108 Emerald Hills Or
FIRE PREVENTION /O
SAFETY SURVEY
A
PHONE: 4256701400
ADDRESS: Edmonds 98020
BUSINESS OWNER: Waterfront Coffee Co. HOME PHONE: 4256701400
EMERGENCY-1: Pederson, Pat HOME PHONE: 4256722706
KEY ACCESS-2: Cell 425-876-4000 HOME PHONE:
"AR�NCY STATE 8 LS1�1IFT
SCHEDULED 10/01/10
DATE DUE ►
UFIR ► 513 "(202
ACTIVE
f•Isz
INITIAL INSPECTION DATE
PERSON 1. CONTACTED: � �Gr " e
NAME OF INSPECTOR: N TL 2_ Gt �j (� ' , ` / ... n
FIRE O
SYSTEMS:
�VIVUAL
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS r
N Do Q J �v,s' f`i y �A //v a CI d a 'e 6)IA l.S
ENTER CODE ONLY ONCE ►
VIOLATION CODE
1
2 111cve a l- ff'q �'/2C cicy
2
3 esIiave DNA 4Ut? r_Ox uc,'x,
3
4`�
4
7 G
w.5 XOtFnl /—1 `�L� �y� • J� n �!� , V f d fvG �CC�S�
5
i
6
6
7
7
)
8 *
8
1st 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: / 7 , J
DATE:
DATE: _
3
OLATION
1 l.i 5
VIOLATIONS
1 5
PRE-CRATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2 O
6
2
6
DATE:
CODE
SECTION: _
5
3 D
7
3
7
RETURN RECEIPT
RECEIVED
6
7
4
18
4
18
DATE:
DISPOSITION:
8
LETTER NEEDED ] YES E] NO
LETTER NEEDED ❑ YES 0 NO
FIRE DEPARTMENT COPY
�0 � ��� � i 3 6 o o�
CITY OF. EDMONDS
BUSINESS LICENSE APPLICATION- COMMERCIAL
FEE: $125.00
CITY CLERK'S OFFICE; BUSINESS LICENSE DIVISION
�"C• 1g9) 121 5' AVENUE NORTH, EDMONDS, WA 98020 PHONE: 425.775.2525
14" 1 R{J%l i IVM,: rlease complete the application In full and attach the required floor plan. Middle initial. or name required of all
parties concerned. If no middle name, please indicate by writing NMN. Sign and return application with fee. Please advise of
any change in'status. New license required if business changes location or ownership. Notification to City of Edmonds required
if business closes.
BUSINESS NAME
BUSINESS ADORE
MAILING ADDRESS /.0 J f(Ja,
Street or rU Box Suite No. City, State and Tap Code L[1 d
BUSINESS PHONE NO.4k10 WA STATE TAX ID NO. (UBI NO.) C0.3 " 406
BUSINESS E-MAIL L' ®(� I�'�� �eCp , Cd� BUSINESS WEBSITE t!/J kJ l
PROPERTY OWNER P r 412,5- A/ _ "7
Name.
Phone Number
NOTIFICATION (For Premise Access in Emergency):
name
MI Phone
Last Name First Name—)
Mi Phone No.
NATURE OF BUSINESS
r
'NUMBER OF EMPLOYEES SQUARE FOOTAGE OF BUSINESS SPACE 77�Q
TYPE OF BUSINESS - PLEASE CHECK THE APPROPRIATE CATEGORY:
O CONSTRUCTION...O FINANCE, INSURANCE, REAL ESTATE O LANDSCAPE, HORTICULTURAL O MANUFACTURING. O NON-PROFIT
ETAIL ECONDHAN_D DEALER 0 SERVICES. O WHOLESALE. O.OTHER
AMUSEIIMENT°DEVICES- ON PREMISES? OYES NO IF YES, .TOTAL NUMBER
LI000WSOLU ON PREMISES?:'
O YES
NO GAMBLING? OYES O NO CIGARETTES SOLD ON PREMISE$?_OYES
FLAMMABLE OR HAZARDOUS. MATERIALS USED OR STORED?: 0 YES WO. IF YES, PLEASE PROVIDE UST OF MATERIALS AND QUANTITIES:
PROPOSED OPENING DAY OF BUSINESS �� �� ��(� BUSINESS HOURS �� 7/
DAYS OPEN �SUNDAY )(MONDAY )(TUU'E]SDAY )(WEDNESDAY XTHURSDAY KFRIDAY SATURDAY
PARKING SPACES ON SITE: TOTAL / ACCESSIBLE FORPERSONS WITH DISABILITIES
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? �YES O NO
PREVIOUS BUSINESS USE AT THIS ADDRESS �
SOLE PROPRIETORSHIP
NAME_
Last First
MI
ADDRESS
Street Apt No.. Unit No. City. State and ZJp Code
HOME PHONE NO. L_, DOL NO. (DRIVERS LICENSE NO.) OR OTHER ID NO.
DATE OF BIRTH CITY AND STATE OF BIRTH COUNTRY OF BIRTH
PARTNERSHIP - PARTNER 1
Last - - First
ADDRESS
Street
Apt No.. Unit No.
HOME PHONE NO.() DOL NO. (DRIVERS LICENSE NO.) OR OTHER ID
DATE OF BIRTH -_CITY AND STATE OF BIRTH
PARTNERSHIP - PARTNER 2
City. State and Zip Code
_._COUNTRY OF BIRTH
NAME _ _
Last First MI
ADDRESS
Street ApL No., Unit No. City, State and Zip Code
HOME PHONE NODOL NO. (DRIVERS LICENSE NO.) OR OTHER 1D NO,
DATE OF BIRTH CITY AND STATE OF BIRTH COUNTRY OF BIRTH
NAME OF CORPORATION K/ 4 P/l / ,r - � FEDERAL TAX 10 NO. (d/—A Z / / &
CORP. ADDRESS �Q 1/ /�/ �ZO�I�S _,f >1J PHONE NO.
Street Suite, Apt., Unit No. City, Slate and Zip Code
CORPORATE OFFICERS:
Last acne First Name MI Title Dale DOL N0. Dtiv rs L n No.
� es
i
LOCAL CONTACT���t1
Las ame First Name MI Title Phone No. p ;
APPUCNqT
i t True Oa j
I
CITY, USE ONLY:
' "Ft NING DEPT.
O APPROVE
O DISAPPROVE
DATE
SIGNATURE
ZONINGCODE
CONDITIONAL USE PERMIT
COMMENTS
BUILDING DEPT.
O APPROVE
O DISAPPROVE
DATE
SIGNATURE
OCCUPANT LOAD
BUILDING PERMIT
OCCUPANCY GROUP
COMMENTS
FIRE DEPT.
O APPROVE
O DISAPPROVE
DATE
SIGNATURE
U. F.1. R.
_
COMMENTS
POLICE DEPT.
O APPROVE
O DISAPPROVE
DATE
SIGNATURE
COMMENTS
i