111 4TH AVE N_Redacted= CITY OF EDMONDS
BUSINESS LICENSE APPLICATION— COMMERCIAL
FEE: $125.00
CITY CLERK'S OFFICE, BUSINESS LICENSE DIVISION
Inc. 11 121 5TM AVENUE NORTH, EDMONDS, WA 98020 PHONE: 425.775.2525
OFFICE USE ONLY
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Year
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Fee 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.
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BUSINESS NAME v«7� E%-CC Q
BUSINESS ADDRESS Ij
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^Street Suite No. Zip Code
MAILING ADDRESS
Street or PO Box Suite No. City, State and Zip Code [
BUSINESS PHONE NO. zs 7 7 rS' Z377 WA STATE TAX ID NO. (UBI NO.) 4/'0' �C� 7 ? j7J 3 7
BUSINESS E-MAIL (/ SSIO Qi'Y(u¢� t� ►�lSt^ • BUSINESS WEBSITE ADO �1-(."T- ✓
PROPERTY OWNER /1ILvI ��.r'�•Ke r' .Lo '7-7O t(�S
Name Phone Number
EMERGENCY NITIFICATION (For Premise Access in Emergency):
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Last me First Name MI Phone No.
Last Name First Name
4�ok �� 1 MI Phone No.
NATURE OF BUSINESS U'S
EED
NUMBER OF EMPLOYEES _SQUARE FOOTAGE OF BUSINESS SPACE 3 O D il/
TYPE OF BUSINESS - PLEASE CHECK THE APPROPRIATE CATEGORY:
O CONSTRUCTION O FINANCE, INSURANCE, REAL ESTATE O LANDSCAPE, HORTICULTURAL O MANUFACTURING O NON-PRFIT
DETAIL OrSECONDHAND DEALER O SERVICES O WHOLESALE O OTHER
AMUSEMENT DEVICES ON PREMISES? O YES d'NO IF YES, TOTAL NUMBER
LIQUOR SOLD ON PREMISES?: O YES �NO GAMBLING? O YES
ZNO
17 NO CIGARETTES SOLD,ON PREMISES? O YES 19<0
FLAMMABLE OR HAZARDOUS MATERIALS USED OR STORED?: O YES IF YES, PLEASE PROVIDE LIST OF MATERIALS AND QUANTITIES:
PROPOSED OPENING DAY OF BUSINESS '7I/O l l s- BUSINESS HOURS A9 -G O(-S,1 l - S e'&.
DAYS OPEN NDAY b-M NDAY Q UESDAY RWEDNESDAY WfHURSDAY OrFRIDAY CY"SATURDAY
PARKING SPACES ON SITE: TOTAL ACCESSIBLE FOR PERSONS WITH DISABILITIES LS
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TL/P..O PERSONS WITH DISABILITIES? LJYES O NO
PREVIOUS BUSINESS USE AT THIS ADDRESS `` � MI Jhe L-d— BI — / � r -t—
ADDRESS
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• FLOOR PLAN < �.
FIRE PREVENTION
Serving Brier; Edmonds;
12425 Meridian Ave S
INSPECTION REPORT
sNoxoisx co.
FIREMountlake Terrace, and
Everett, WA 98208
❑ ❑ BRIER BRIEREDMOS
- th11?e Town of Woodway
STRIT
Phone (425) 551-1200
❑ WOODWAY
❑ AKE TERRACE
Yt'WFireDistrlctl.Org
Fax (425) 551-1272
❑ UNINCORPORATED
FREQUENCY STATION & SHIFT
LOCATION: 111 4th Ave N
365 17 A
I
BUSINESS NAME: Embellished, Inc.
PHONE: 20671834697
SCHEDULED
DATE DUE ► i a/01113
MAILING 111 4th Ave N
UFIR ► 549 3202 ;
ADDRESS: Edmonds
98020
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BUSINESS OWNER: RBlschling,Xa" c�
HOME PHONE: 4254783030
ACTIVE
EMERGENCY-1: s
Third Ave S Properties
HOME PHONE: 4256706799
CURRENT
KEY ACCESS-2:
HOME PHONE:
CITY • _YES NO
BUSINESS
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LICENSE
PERSON CONTACTED:
INITIAL INSPECTION DATE
NAME OF INSPECTOR: r� �
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FIRE
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SYSTEMS: ,®
ANNUAL
HAZARDS F UND AND LOCATIONS / COMMUNICATIONS
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5
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6
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1 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
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DATE: v ,r
DATE:
DATE:
3
1
1 LATIONS
15
VIOLATIONS
1 15
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2
6
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED
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4
8
4
8
DATE:
DISPOSITION:
LETTER NEEDED ❑ YES Ej NO
LETTER NEEDED ❑ YES ❑ NO
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FIRE DEPARTMENT COPY ,
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FIRE PREVENTION
a , Serving Brier, Edmonds
12425 Meridian Ave S
INSPECTION REPORT
SNOHOMISH CO. I n . - • -
Moz�ntlake Terrace and .
FIRE
Everett WA 98208
Everett, - .,
EDMONDS
BRIER
the'Town of Woodway
DISTR
Phone (425) 551-1200
❑WOODWAY
❑ MOUNTLAKE TERRACE
www FireDistrict].org
Fax (425) 551-1272
❑ UNINCORPORATED
FREQUENCY STATION & SHIFT
LOCATION: 111 4th Ave N
365 17 O
BUSINESS NAME: �� Mt3(t�81 ASS
PHONE: 2062617015
SCHEDULED /
DATE DUE ► 03101, 12
MAILING 1114th Ave N /
C
UFIR ► 141 3202
ADDRESS: Edmonds
Wilson, Andy90020
BUSINESS OWNER: HOME PHONE: 2062617015
IL6,�EMERGENCY-1:
ACTIVE
Thlyd Aye S Pro ertles�ayHOME PHONE: 4256706799
CURRENT
YES NO
KEY ACCESS-2: HOME
PHONE:
CITY
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BUSINESS
❑ ❑
PERSON CONTACTED:
INITIAL INSPECTION DATE
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NAME OF INSPECTOR: 57' ' - W! x/ K/ ` Ol 0
FIRE
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SYSTEMS:
ANNUAL
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HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
1
1
2
2 -
3
3
4
4
5
15
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
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
8
4
8
4
8
DATE:
DISPOSITION:
7
LETTER NEEDED ❑ YES ❑ NO
LETTER NEEDED ❑ YES ❑ NO
8
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FIRE DEPARTMENT COPY `
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CITY OF EDMONDS
BUSINESS LICENSE APPLICATION- .COMMERCIAL
FEE: $125.00
CITY CLERICS OFFICE, SUSINESS'LICENSE DIVISION
121 5' AVENUE NORTH, EDMONDS. WA 98020 PHONE: 425.775.2525
OFFICE USE ONLY
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4,7010 -7a��
SIC
Year
Class
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SHD
Date Paid
c -/-i
3 3
Fee Paid
Mailed
Delete
INSTRUCTIONS: Please complete the application in full and attach the required floor plan. Middle initial or name required of all
parties concerned. If no middle name, please indicate by writing NMN. Sign and return application with fee. Please advise of -
any change in status. New license requited if business changes location or ownership. Notification to City of Edmonds required
If business closes.
BUSINESS NAME E rn hQj l l..s h e d -- ne.,
BUSINESS ADDRESS
MAILING ADDRESS 5 IA I I I C
Street or PO Box Suite No. City, State and Zip Code
BUSINESS PHONE NO. O (Q 1 / 9' - y WA STATE TAX 11) NO. (UBI NO.)
BUSINESS E-MAIL & h Q e D n n Q & 0.QM n 1L BUSINESS WEBSITE 1.1llAtl ll ('� /11 bCC II i �C h - i n l! Om
PROPERTY OWNER _h I� i d Aug S Pr /) `� �� 7 Q
Name Phone Number
NOTIFICATION (For Pnardse Aooess in Emergency):
MI
0A_
MI Phone No.
NATURE OF BUSINESS _A ri / nS hile h o6 p a lon i'i 0a � c� Ire !
'qbal e - rid. ho r and tvnp
NUMBER OF EMPLOYEES o! SQUARE FOOTAGE OF BUSINESS SPACE /_')OQ
TYPE OF BUMNES$ - PLEASE CHF_CK.THE•APPRQPRIATE CATEGORY-
0 CONSTRUCTION . Q FINANCE. INSURANCE. REAL ESTATE- O LANDSCAPE, HORTICULTURAL O MANUFACTURING O NON-PROFIT
,O RETAIL O- SECONDHAND WLER �ERVICES O WHOLESALE DOTHER
AMUSEMENT DEVICES ONi REMISES? .d YES .0 NU . IF YES. TOTAL NUMBER
LIQUOR SOLD ON PREMISES?:- -,(YES. d NO, GAMBLING? O YES P'NO CIGARETTES SOLDON PREMISES? OYES NO
KAMMABLE OR HAZARDOUS MATERIALS USED OR STORED?: CI YES V(NO IF -YES; PLEASE PROVIDE UST OF MATERIALS AND QUANTITIES:
PROPOSED OPENING DAkOFBUSINESS _ tle %y ZO/Z BUSINESS HOURS ArOnUSOc>! —I'%rQ/h
DAYS OPEN & UNDAY 01MONDAY JeTUESDAY R(WEDNESDAY 01HUR$DAY IfRiDAY •grSSATURDAY
PARKING SPACES ON SITE: TOTAL ACCESSIBLE FOR PERSONS WITH DISABILITIES ) Peg
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? OfES ONO
PREVIOUS BUSINESS USE AT THIS ADDRESS eJL,
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