110 W DAYTON ST STE 104_RedactedIIII��III I i o w F'oyTvri s- s; E I d V
RECTIVED
CITY OF EDMONDS
BUSINESS LICENSE APPLICATION — COMMERCIAL 13 ❑ Building
.i ONESCITY CM FEE: $125.00 Fire
El Planning
CITY CLERK'S OFFICE, BUSINESS LICENSE DIVISION ❑ Police
121 5TH AVENUE NORTH, EDMONDS, WA 98020 PHONE 425.775.2525
OFFICE USE ONLY
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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 314S each year. Renewal
must be submitted prior to January 3'I" to avoid late fees.
BUSINESS NAME ILLUMAGEAR, Inc.
BUSINESS ADDRESS 110 W. Dayton St. 105 Edmonds, WA, 98020
Street Suite # City, State, Zip Code
MAILING ADDRESS 1752 NW
Street or PO Box # Suite # City, State, Zip Code
BUSINESS PHONE! 206 t 973-4277 WA STATE TAX ID # (UBI) 16
10
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BUSINESS E-MAIL MaxO-illumagear.com BUSINESS WEBSITE www.ILLUMAGEAR.com
BUSINESS OWNER / MAIN CONTACT Max Baker ( 206 ► 973-4277
Name Phone Number
PROPERTY OWNER Harbor Square Business Park (425 t 774-1511
Name Phone Number
EMERGENCY NOTIFICATION (For Premise Access in Emergency):
Raker Max (206 t 240-2798
Last Name First Name MI Phone Number
Conner Jan ( 425 t 77401511
Last Name Fast Name MI Phone Number
NATURE OF BUSINESS (Provide a Detailed Description of Business Activities, Products & Services):
Technology company focused on high -risk worker safety. Office activities include marketing research, sales,
computer engineering work, and misc office chores
SPACE ALTERATIONS TO BE MADE: YES NO X DESCRIPTION
PREVIOUS BUSINESS AT THIS ADDRESS Not Sure
NUMBER OF EMPLOYEES 5 SQUARE FOOTAGE OF BUSINESS SPACE 720
TYPE OF BUSINESS - PLEASE CHECK APPROPRIATE CATEGORY:
❑ CONSTRUCTION
❑ FINANCE, INSURANCE, REAL ESTATE
O LANDSCAPE, HORTICULTURAL
❑ MANUFACTURING
❑ NON-PROFIT
❑ RETAIL
❑ SECONDHAND DEALER
❑ SERVICES
❑ WHOLESALE
X OTHER
PROPOSED OPENING
BUSINESS HOUR&NA to public - 8a to 5p
DAYS OPEN:
❑ SUNDRY X WEDNESDAY
X MONDAY XTHURSDAY
X TUESDAY X FRIDAY
❑ SATURDAY
AMUSEMENT DEVICES ON PREMISES? YES_ NO IF YES, TOTAL NUMBER LIQUOR SOLD ON PREMISES? YES NO
GAMBLING? YES_ NO__X._ CIGARETTES 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 NA ACCESSIBLE SPACES FOR HANDICAP PARKING
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? YES X NO
ECIJIVED
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NAME OFCORPOMTION, u,t,tJS�Dr`FDR FEOERALTA%OR-
CGRFALCREGS 1752 NW Market St. # 733 SeatNe, WA, 96017
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0 DISAPPROVE DATE
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PLNININGOEPT. O APPROVE Q D6A CW DATE MMATINE
2ONNOCOCE CONMONALUBEPERMR COMMENTS
POLICE OUT. 0 AWROVE O DMAPFWE DATE
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Exhibit "A" REC-Eff VE D
APR 17 2017
HARBOR SQUARE BUSINESS PARK
Suite 105, 110 W. Dayton Street, Edmonds E"JONIOXYr, UTY CLERK
REVI&EID FLOOR PLAN
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CITY OF EDMONDS
BUSINESS LICENSE APPLICATION- COMMERCIAL
FEE: $125.00
CITY CLERK'S OFFICE, BUSINESS LICENSE DIVISION
121 5T' AVENUE NORTH, EDMONDS. WA 98020 PHONE: 425.775.2525
OFFICE USE ONLY
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INSTRUCTIONS: Please complete the application in full and attach the required floor plan. Middle initial or name required of all
parties concerned. If no middle name, please indicate by writing NMN. Sign and return application with fee. Please advise of
any change in status. New license required If business changes location or ownership. Notification to City of Edmonds required
If business closes.
BUSINESS NAME
BUSINESS ADDRESS U VV .
Street
/
MAILING ADDRESS O ✓'�
Street or PO Box
BUSIN SS PHONES NO. ��Z10_)?
BUSIN� S E MAIL �-S
PROPERTY OWNER Sa'
Name
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Suite No. Zip Code
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Suite No. City, State and Zip Code
WA STATE TAX ID NO. (UBI NO.) (go I 355 59127
• CD M BUSINESS WEBSITE r1L101W
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Phone Number
EMERGENCY NOTIFICATION (For Premise Access in Emergency):
A . . ..
Last Name
First Name
C.
Name" First Name Mi Phone No.
TYPE OF BUSINESS - PLEASE CHECK THE APPROPRIATE CATEGORY:
O CONSTRUCTION O FINANCE, INSURANCE, REAL ESTATE O LANDSCAPE, HORTICULTURAL O MANUFACTURING O NON-PROFIT
'&(RETAIL O SECONDHAND DEALER SERVICES O WHOLESALE O OTHER H . ep% l Vi Ir( LS L G Sd
AMUSEMENT DEVICES ON PREMISES? O YES XNO IF YES, TOTAL NUMBER ' i- �e-s, 0 ns
LIQUOR SOLD ON PREMISES?: O YES ANO GAMBLING? O YES 'KNO CIGARETTES SOLD ON PREMISES? O YES %J<NO
FLAMMABLE OR HAZARDOUS MATERIALS USED OR STORED?: O YES *0 IF YES, PLEASE PROVIDE LIST OF MATERIALS AND QU4-ATI15Sj
PROPOSED OPENING DAY OF BUSINESS S BUSINESS HOURS Za — Z12in
DAYS OPEN O SUNDAY O MONDAY ___';$� ESDAY ,�WEQ; �S Y HURSDAY G>d`RIDAY WSATURDAY
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PARKING SPACES ON SITE: TOTAL ��• ACCESSIBLE FOR PERSONS WITH DISABILITIES Me,
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES?
PREVIOUS BUSINESS USE AT THIS ADDRESS Vl 6 y) 2,
)kYES O NO
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DOL NO.(DRIVERS LICENSE NO.) OR OTHER ID NO
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NAME OF CORPORATION
FEDERAL TAX IDNO.
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PHONE NO(_J
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PLARING DEPT. ❑APPROVE
0DISAPPROVE DATE SIGNATURE
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SUS.ONG DEPT. OAPPROVE
ODISAPPROVE DATE SIGNATURE
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OCCUPANTLOAD
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OOISAPPROVE DATE SIGNATURE
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POLICE DEPT. OApPROVE
ODISAPPROVE DATE SIGNATURE
I COMMENTS
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High -Profile Location
HARBOR SQ BUSINESS COMPLEX!
w EDMONDS, WASHINGTON ■ 98020
Suite 1L
➢, .8able Square Feet"
➢ $/.yr, NNN
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FIRE PREVENTION
, � d
f Serving' Br ier, Edrnonds', 12425 Meridian Ave S
INSPECTION REPORT
SNOHOIVIISH-CO.
EDMONDS
11LlBRIER
�. ����
Mountlake Terrace,and
Everett, WA 98208
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TR
the Town of Woodway ,
FireDistrictl.
. Phone (42S) 551-1200
❑ MO NTLAY
❑ TERRACE
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www org .
Fax (425) SSl -1272
UNINCORPORATED
❑UNINCORPORATED
FREQUENCY STATION & SHIFT
LOCATION:
110 West Dayton Street Suite 1044,98020
2 Year 13 17-B
BUSINESS NAME:
{ � � �°°
PHONE: 42 7.7'll��r" SCHEDULED Sep
DATE DUE
r
MAILING
UFIR ►
ADDRESS:
110 West Dayton Street, Suite 104, Edmonds, WA 9 0 0
BUSINESS OWNER:
HOME PHONE:
Email:
EMERGENCY-1: 'Z_WE I V:4G' R 571F(/E7'Q
HOME PHONEI 7,D 7-5'YQ
r CURRENT
KEY ACCESS-2:
HOME PHONE:
CITY YES NO
BUSINESS
LICENSE
PERSON CONTACTED:
IIN�SPECTION DATE
INITIAL INSPECTION
NAME OF INSPECTOR:
C �j SJ� t ^i
to — 17 I
FIRE SYSTEMS:
FE 3 '!_J_�
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
e
1 C E 1
1 Fe
2
2
3
3
a
-6
6
7
1 7
I AGREE TO CORRECT,.THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1st RE -INSPECTION
2nd RE -INSPECTION
FINAL RE -INSPECTION
EXTENSION
VIOLATIONS
DATE DUE:
DATE DUE:
GRANTED TO:
DATE DUE:
CITED:
PERSON
PERSON
PERSON
CONTACTED:
CONTACTED:
CONTACTED:
1
INSPECTOR. -
INSPECTOR.
INSPECTOR:
2 -
DATE:
DATE:
DATE:
VIOLATIONS
VIOLATIONS
PRE -CITATION
CITATION ISSUED
1 5
. •
1" 5
LETTER SENT
NUMBER:
4
'
CODE
8
2
6
\\
2
6
DATE.
SECTION:
.' ,.;4a;;•
RETURN RECEIPT
3
7
3
7
RECEIVED
6
DISPOSITION:
4
8
4
8
DATE:
LETTER NEEDED ❑ YES ❑ NO
LETTER NEEDED ❑ YES ❑ NO
8
FIRE DEPARTMENT COPY
5'
CITY OF EDMONDS
121 5rH AVENUE N. EDMONDS, WASHINGTON 98020 (425) 771-0215
FIRE DEPARTMENT
FIRE PREVENTION
SAFETY SURVEY
LOCATION: 110 W. Dayton Street 104
�I
J BUSINESS NAME: Blueprint Management Inc. PHONE: 4257761245
J
MAILING 110 W. Dayton St #104
ADDRESS: Edmonds 98020
BUSINESS OWNER: Herman, Doug HOME PHONE: 2069498893
EMERGENCY-1: Hyland, Shannon HOME PHONE: 4257440484
KEY ACCESS-2: HOME PHONE:
FREQUENCY
STATION & SHIFT
731
17 C
►
09/01/10
DATE DUES
UFIR ► 591
9202
ACTIVE
PERSON CONTACTED: "0 N cf— INITIAL INSPECTION DATE '}
NAME OF INSPECTOR: S h ,t (� ' O , / -7 ` [ / /v
FIRE FE ;j0
SYSTEMS: ANNUAL
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
1
ENTER CODE ONLY ONCE ►
VIOLATION CODE
1
2 LA
2
3
�
�''
3
4
4
5
5
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:
DATE:
DATE: _
3
VIOLATIONS'
1 5
VIOLATIONS
1 5
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2
6
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED
6
7
4
a
4
B
DATE:
DISPOSITION:
8
LETTER NEEDED ❑ YES ❑ NO
LETTER NEEDED ❑ YES ❑ NO
FIRE DEPARTMENT COPY