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JAN CITY CLERK'S OFFICE, BUSINESS LICENSE DIVISION
121 57" AVENUE NORTH, EDMONDS, WA 98020 PHONE 425.775.2525
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` OFFICE USE ONLY
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I Date Paid
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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 31" each year. Renewal
must be submitted prior to January 31" to avoid late fees. ((�� (� j f j / n �- n n
BUSINESSNAME gejskph.%S EuT%(,ises.L' ,G di�0. I�l1da6o. �Z—ay2Nfl ey` L.�Lm-wids-
BUSINESS ADDRESS_ _ I O 2 �^ a A ue , N . 7 Pno N�S , 9 Q
Street Suite # City, State, Zip Code
MAILING
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Street or PO Box # Suite # City, Stat6, Zip Code
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BUSINESS PHONE{ 14 Z-►5{� 1,,�� ( 1 — Q-7 6 3 WA STATE TAX ID # (UBI) 1610 3 5 I I 5 q
BUSINESS E-MAIL �, r`�'rfJrO' IC�-7Z(a-;(p�IV�(��. ` ,CO � BUSINESS WEBSITE
BUSINESS OWNER /MAIN CONTACT 4) S0. R a&ICk— i �-(Zrj t f 8 - 0%15 'g
Name Phone Number
EMERGENCY NOTIFICATION (For Premise Access In Emergency):
First Name
Last
MI
1
Last Name First Name MI Phone Number
NATURE OF BUSINESS (Provide a Detailed Description of Business Activities, Products & Services):
��Gi l STod�e Se.II'/Nc G,aUeN�er �f'y`OdticTS
SPACE ALTERATIONS TO BE MADE: YES_NO2�DESCRIPTION
PREVIOUS BUSINESS AT THIS ADDRESS _ice/ F) M As C&+*-QV ST ny-i
NUMBER OF EMPLOYEES -I- SQUARE FOOTAGE OF BUSINESS SPACE
TYPE OF BUSINESS - PLEASE CHECK APPROPRIATE CATEGORY:
CONSTRUCTION
FINANCE, INSURANCE, REAL ESTATE
r: LANDSCAPE, HORTICULTURAL
L! MANUFACTURING
L_ NON-PROFIT
:16 RETAIL
L SECONDHAND DEALER
SERVICES
WHOLESALE
L. OTHER
PROPOSED OPENING
BUSINESS HOURS: / (� 0V _ 190,
DAYS OPEN:
.17 SUNDAY WEDNESDAY
❑ MONDAY THURSDAY
VTUESDAY ,D.I( FRIDAY
XSATURDAY
AMUSEMENT DEVICES ON PRE ISES? YES NO IF YES, TOTAL NUMBER LIQUOR SOLD ON PREMISES? YES ' NO r�
GAMBLING? YES_ NO6� CIGARETTES SOLD ON PREMISES? YES NO
FLAMMABLE OR HAZARDOUS MATERIALS USED OR STORED? YES NO—JeLl,IF YES, PLEASE PROVIDE A LIST OF MATERIALS AND QUANTITIES:
PARKING SPACES ON SITE: TOTAL SPACES 0 ACCESSIBLE SPACES FOR HANDICAP PARKING,_
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? YES NO
APPLICANT
NAME f.^ S G
Printed Name nn Sgignature
TITLE I Y 1A N AC2 - DATE 3 / ? D/ %
Applications may be mailed in with a check, brought in person, faxed to 425-771-0266 or emalled to business.license@edmondswa.trov
with a valid phone number. We will call you for a Visa or MasterCard payment.
50LE-PROPRIETORSHIP
LAST FIRST MIDDLE INITIAL
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STREET SUITE/APT/UNIT # CITY/STATE/ZIP CODE
HOME PHONE( 1 DRIVERS LICENSE OR ID # & STATE
DATE OF BIRTH_ CITY/STATE OF BIRTH COUNTRY OF BIRTH
PARTNERSHIP- PARTNER 1
NAME
LAST
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ADDRESS
STREET
SUITEIAPT/UNIT #
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CiTYISTATE/ZIP CODE
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DRIVERS LICENSE OR ID # & STATE
DATE OF BIRTH
CITY/STATE OF BIRTH COUNTRY OF BIRTH
PARTNERSHIP - PARTNER 2
NAME
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SUITE/APT/UNIT #
CITY/STATE/ZIP CODE
HOME PHONE(
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DRIVER'S LICENSE OR ID # & STATE
DATE OF BIRTH
CITY/STATE OF BIRTH COUNTRY
OF BIRTH
NAME OFCORPORATION.
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0743
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Phone Number
CITY USE ONLY
BUILDING DEPT.
APPROVE
0
DISAPPROVE
DATE
SIGNATURE
OCCUPANT LOAD
BUILDING PERMIT
OCCUPANCY GROUP
COMMENTS
ENGINEERING
Q APPROVE
DISAPPROVE
DATE
SIGNATURE__ _
FIRE DEPT
APPROVE
DISAPPROVE
DATE
SIGNATURE—
U. F. 1. R.
COMMENTS
PLANNING DEPT
Q APPROVE
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SIGNATURE
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CONDITIONAL USE PERMIT
COMMENTS
POLICE DEPT 0 APPROVE Q DISAPPROVE DATE SIGNATURE_
COMMENTS ___ _
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Serving Brier, Edmonds, and
Mountlake Terrace
www.FireDistrictl.org
12425 Meridian Ave S
Everett, WA 98208
Phone (425) 551-1200
Fax (425) 551-1272
LOCATION:
102 5 th Avenue N Suite B 98020
BUSINESS NAME: PHONE:
Nama's Candy Store 4257714606
MAILING
ADDRESS:
102 5th Avenue N, Suite B, Edmonds, WA 98020
BUSINESS OWNER: HOME PHONE:
FIRE PREVENTION
INSPECTION REPORT
lQEDMONDS
❑ BRIER
❑ MOUNTLAKE TERRACE
❑ UNINCORPORATED
FREQUENCY STATION & SHIFT
SCHEDULED
DATE DUE /
UFIR /
519 203
EMERGENCY I: HOME PHONE: CURRENT
KEY ACCESS-2: McKee, George HOME PHONE: 4257758097 CITY YES NO
BUSINESS V I
EMAIL: n /+^ G C <�a� O ti '>2 (� Ihc�L Gu^% LICENSE /L>hu
n
INITIAL INSPECTION DATE
PERSON CONTACTED:
NAME OF INSPECTOR: -Y
FIRE SYSTEMS:, FE 8/12
DMtmtc8avAisedocATIONS / COMMUNICATIONS
2'��
2
3
3
4
5
6
4-
5
6
7
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1 st 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:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
4 .
5
6
- -
VIOLATIONS
15
2
3
VIOLATIONS>
1
2
3
...
4
,
5
6
7
......_..__.._...
8
PRE -CITATION
LETTER SENT
DATE:
CITATION ISSUED_
NUMBER:
CODE
SECTION:
� 6
7
_ _
RETURN RECEIPT _
RECEIVED
..��®_..
DISPOSITION: .____. _........,._.
._,. , �.._d.
4
8
DATE:
.....
LETTER NEEDED ❑ YES ❑ NO
_
LETTER NEEDED ❑ YES ❑ NO
8
FIRE PREVENTION
ServingBrier, Edmonds
- 1251 Meridian Ave S
INSPECTION REPORT
SNOHOMISH CO.
FIRE''
Mountlake Terraceand
" "Everett, WA 9s20s❑
BREROEDIVIONDS
DISTh
� the Town of Woodway
Phone (425) 551-1200
❑ WOODWAY
❑ AKE TERRACE
www FireDistrictl. org
Fax (42S) SSI -1272
❑UNINCORPORATED
UNINCO
'
FREQUENCY
STATION & SHIFT
LOCATION:
102 5th Ave N
B
731
17 A
BUSINESS NAME:
Nema's Gen St
�"Y ore
PHONE: ,4257714606
SCHEDULED
DATE DUE ► 06/01/13
MAILING
102 5th Ave N #13
UFIR ► 519 6203
ADDRESS:
Edmonds
93020
BUSINESS OWNER:
McKee, George
HOME PHONE: 4257758097
ACTIVE
EMERGENCY-1:
McKee, Annette
HOME PHONE: 2068536801
CURRENT
KEY ACCESS-2:
HOME PHONE:
CITY YES NO
BUSINESS
LICENSE
PERSON CONTACTED: r a' r L
INITIAL INSPECTION) DATE
NAME OF INSPECTOR:
l!J � l3
FIRE
FE(Z;_LL
* \\
SYSTEMS: Ov
� �
ANNUAL
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
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:
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
i 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 '
4
18
•
4
18
DATE:
DISPOSITION:
7
LETTER NEEDED ❑ YES ❑ NO
LETTER NEEDED ❑ YES ❑ NO
e
FIRE DEPARTMENT.COPY
CITY O;F EDMONDS_
r 121 5TM AVENUE N. • EDMONDS, WASHINGTON 98020 (425) 771-0215
FIRE DEPARTMENT
4�'St. 189�
I
LOCATION: 1021 5th Ave N
BUSINESS NAME: Nana S Candy Store
MAILING 102 5th Ave N #I?B
or
------------
FIRE PREVENTION
SAFETY SURVEY
B
PHONE: 4257714606
ADDRESS. Edmonds 98020
4 BUSINESS OWNER: ' McKee; George HOME PHONE: 4257758097
EMERGENCY-1: McKee, Annette HOME PHONE: 2068536501
II
KEY ACCESS-2: HOME PHONE:
FREQUENCY STATION & SHIFT
731 17 B
SCHDATEEDUEE ► 06/01/10
UFIR ► 519 6203
ACTIVE
�� INITIAL INSPECTION DATE
PERSON CONTACTED:
NAME OF INSPECTOR:`
FIRE FE _!_
SYSTEMS: ANNUAL
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS t
ENTER CODE ONLY ONCE ►
VIOLATION CODE
2
2
3
3
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4
5
5
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7
7
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8
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1st RE -INSPECTION
DATE DUE:
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'
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
1
DATE. ��
DATE.
DATE.
3
VIOLATIONS
1 15
VIOLATIONS
1 5
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
-++
2
6
2
6
DATE:
CODE
SECTION: _
5
3
7
3
7
RETURN RECEIPT
RECEIVED
6
7
4
8
4
8
DATE:
DISPOSITION:
-
8
LETTER NEEDED ❑ YES ❑ NO
LETTER NEEDED ❑ YES ❑ NO
FIRE DEPARTMENT COPY