110 JAMES ST 104_2_Redacted104
''_' °� MAR 14 2o18 CITY OF EDMONDS
♦ BUSINESS LICENSE APPLICATION - COMMERCIAL
M S of y oLm FEE: $125.00
CITY CLERK'S OFFICE:, BUSINESS LICENSE DIVISION
121 5T" AVENUE NORTH, EDMONDS, WA 98020 PHONE 425.775.2525
❑
Building
❑
Engineering
❑
Fire
❑
Planning
❑
Police
OFFICE USE ONLY
BL#
Customer # SIC
I Year
CI s
I SHD
rate Paid
TR# e
Mailed 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 31" each year. Renewal
must be submitted prior to January 31s` to avoid late fees.
Psychiatric Wellness & Dementia Care. LLC
BUSINESS NAME
BUSINESSADDRESS 110 .lames Street Suite 104 Edmonds, WA 98020
Street Suite fi icily. Stata, Zip Code
711 fl 106 Pl AW Lynnwood, WA 98036
MAILING ADDRESS
Street or PO Sox # Suite 9 c- City, State, Zip Code
BUSINESS PHONE 206 4591158 WA STATE TAX ID # (U51) 603 230- 72
wellness@tatianasadak.com tatianasadak.com
BUSINESS E.-MAIL _ BUSINESS WEBSITE
Tatiana Sadak
BUSINESS OWNER! M0.IN CONTACT� t 206 4�9.1158
Name Phone Number
PROPERTY OWNER
Christina Hughes f 206-512-4846
—7
Name Phone Number
EMERGENCY NOTIFICATION (For Premise Access in Emergency}:
Hughes Christina f 206-51 ?-4846
Lact,Name First Name MI Pnane Number
Last Name First Name MI Phone Number
NATURE OF BUSINESS (Provide a Detailed Oescription of Business Activities, Products & Services]:
Psychiatry Private Practice
SPACE ALTERATIONS TO BE MADE- YES NO_X_ DESCRIPTION
PREVIOUS BUSINESS AT THIS ADDRESS s bi-leasing space one weekend a month from Spero Consulting
NUMBER OF EMPLOYEES 1 SQUARE FOOTAGE OF BUSINESS SPACE 9 x 12
TYPE OF BUSINESS - PLEASE CHECK APPROPRIATE CATEGORY:
❑ CONSTRUCTION
❑ FINANCE, tNSURANCE, REAL ESTATE
ci LANDSCAPE, HORTICULTURAL
❑ MANUFACTURING
❑ NON-PROFIT
❑ RETAIL
0 SECONDHAND DEALER
* SERVICES
❑ WHOLESALE
❑ OTHER
PROPOSED OPENING DATE: r
BUS1NESS HOURS: 8am-5pm
DAYS OPEN: every first weekend of the month
SUNDAY o WEDNESDAY
D MONDAY r 1 THURSDAY
D TUESDAY ❑ FRIDAY
IN SATURDAY
AMUSEMENT DEVICES ON PREMISES? YES NO x iF YES, TOTAL NUMBER LIQUOR SOLD ON PREMISES? YES NO x
GAMBLING? YES_ NO x CIGARETTES SOLD ON PREMISES? YES _ NA X
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 ACCESSIBLE SPACES FOR HANDICAP PARKING
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? YESX NO
APPLICANT
iatiana Sadak
NAME
- 741oe-�
Pnnled Name psychiatric Nurse Practitioner, PhD. ARNP 3,9.18 signature
TITLE e a u-'1- DATE
NAME
LAST FIRST MIDDLE INITIAL 1 4 2018
AZ-Rc
PARTNERSHIP -PARTNER 7
NAME
AST
FIRST
MIDDLE INITIAL
ADDRESS
STREET
$URE/pFTNN? M
CRY/STRE/JJP CODf
HOME PHONE(
1
DRIVERS LICENSE OR ID B B STATE
OATEOFBIRTR
CRY/STATE OF GRTX COUNTRY OF BIRTH
PARTNERSHIP - PARTNER 2
NAME
Lp3T
FIRBi
MIOOIE INITIPI
ADDRESS
STPFEI
S11TE/APTNNITI
CRT/STpTEZP CODE
HOME PHONE(
I
DRIVER'S LICENSE OR ID A B STATE
DATE OF BIRTH
CITYISTATE OF BIRTH
COUNTRY OF BIRTH
CORPORATION/LLC or PLLC
msocmcaORPTOu. PSyDtllatie WBIlne S&DeIRP.il11R(.are. LLC FEOERPL TAX IOp
CORE ADDRESS 7110191 St PL SW Lynnwood, WA 98036
( 206 4491158
Street
CORPORATE OFFICERS:
a Jaoaie tanana First Name
Sum, Apt UI9 C'M. State ad Ea Onde
MI
Pnanc Number
Mff/Sate
LOCAL CONTACT SAME
Last Name Filet Name
pM Tille DateofBiM
r )
Drivers Llcunse or Olner lOplSiNe
Pnme Number
CRTUSEONLT.
BUILDING DEPT.
O APPROVE
0 DISAPPROVE
DATE
MGNAIDRE
OCCUPANT LOAD
RUILII PERMT
OCCup.NCY ORW,
COMMENTS
ENGINEERING
APPROVE
Q
DISAPPROVE
DATE
mGNANRE
FIRE DEPT
APPROVE
DISAPPROVE
DATE
SIGNANRE
U£LR.
COMMENTS
PLANNING DEPT
Q APPROVE
O DISAPPROVE
DATE
SIGNATURE
20NING000E
CONDITIONAL USE PERMIT
COMMRJTS
POLICE DEPT = APPROVE Q DISAPPROVE DATE__.. SIGNATURE
COMMENTS
12•
TREATMENT
ROOM
04
10•-1O'X15'-0'
BREAK RM/
WORK RM
:O5 '—
:2'-1 xa'-0-
RECEP.
OFFICE
.CS
POWER/SIGNAL PLAN
SCALE: I /8"=1'-0"
1/8"= l 0"
0 4 8' 16, 32'
PRICINZ PUN
NOTE:
TH 15 P.R Z L1 M: N ARMS PAC a P,AN REPRESENTS 0U.@ :, N D E RSTAHD I.S C 0F'HE 5P42:E PRO C RAM R EZi51 I R E SI ENTS AN
iN C L L OES ",UR I N 7E R PF ETf TdO,L'S OF LOCAL 9H li Di N'v CCDE -1EQUIREMENTS• THE FINAL CONSTR JCTION ❑OCUM°i TS ARE
SUB; ECT FO REVI EJl ANC CO IS IAENT$ FRJNt 7.4E UV4D L, PD AS Ly ELL AS L'J CAL Sp7ERN M E NTAL AGENCIES. ES TO
THE h•ynM MAY S£ REG u'REf. TC AD^RCSS tOM MAN-S AFTEk REV7£W ❑F THE PLAN$TFR15 VCH THE PLAN CKECK PRy"EES
ALL SQUARE FOO'A•SES NOTED ARE PAEL'l4fNARY AND A. SO MAY CHANA. ;yHEN Till: SPAS;--_ PL- N IS FINA':IZED.
CONSJLT,
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MAR 14 2018
EDMONDS CrN CLRK
POWER SIGNAL. NOTES
0 PROVIDE NEW DUPLEX ELECTRICAL OUTLET AT THIS LOCATION,
2 r PROVIDE NEW DEDICATED DUDLEX FOR TENANT PROVIDED COPIER-
0 PROVIDE NEW PHONE/DATA OUTLET FOR TENANT PROVIDED COPIER.
RELOCATE QUAD OUTLET FROM ABOVE COUNTER TO 18"AFF, PROVIDE
PHONE/DATA OUTLET AT THIS LOCATION.
LEGEND
E EXISTING
N NEW
110v. DUPLEX RECEPTACLE. N.OUNTED VERTICALLY AT +18'
A.E.F.. U.O.N.
IL- DEC,CATED 1?Ov./20 AVfP DUPLEX RECEPTACLE, MOUNTED
VEERTiCALLY AT +18" A,F F., V O.N.
I� 110v. DUPLEX RECEPTACLE, MOUNTED 6" ABOVE COUNTER
OR SPLASH.
110y. FOURPiLEX RECEPTACLE. MOUNTED AT +18. O.F.F., U.O.N•
COMBINATION TELEPHONE/DATA OUTLET MUD RING
WALL -MOUNTED AT 18' A.F.F., U.O.N. PROVIDE PULL
ROPE TO ABOVE ACCESSIBLE C6LING SPACE.
IE BLANK PLATE
TEST_FIT
D ENYE9•FQR„AtmETY_ k-DEPRESSION
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