Loading...
7500 212TH ST SW STE 109_108_107 - 15 pgs_Redacted- = o� IRE PREVENTION Serving Brier`, Comonds, and 12425 Meridian Ave S INSPECTION REPORT CID FIR�� Mountlake Terrace Everett, WA 98208 ❑ BR EROEDMONDS Phone (425) .5.51-1200 ❑ MOUNTLAKE TERRACE DISnu- T www.FireDistrict].org Fax (425) 551-1272 ❑ UNINCORPORATED LOCATION: 7500 212 th Street SW Suite 107 98026 BUSINESS NAME: PHONE: 4257753504 MAILING GL /V / L ADDRESS: 7500 212th Street SW, Suite 107, Edmonds, WA 98026 FROE16UENCY ST�TI%& SHIFT SCHEDULED Dec 2016 DATE DUE 591 UFIR ll BUSINESS OWNER: HOME PHONE: EMERGENCY-1: (�ef1t; 7�TTTIIrettLY KEY ACCESS-2: f ��,%� Y S HOME PHONE: �63F71 ��"M %©a 6'�L�HOME ��' S S CURRENT CITY Y Es NO EMAIL: a PHONE: po d C�wt 519 Zi BUSINESS LICENSE E%/ L_J ❑ PERSON CONTACTED: INITIAL INSPECTION DATE NAME OF INSPECTOR: yD f `^ �)4A,' Vr? oi::v FIRE SYSTEMS: FE 3 / / 4.- Date Last Serviced: HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS 1 7/ s 3 4 5 6 I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X 1 2 3 4 _.. '5 6 1st RE -INSPECTION 2nd RE -INSPECTION EXTENSION FINAL RE -INSPECTION VIOLATIONS DATE DUE: DATE DUE: GRANTEDTO: DATE DUE: CITED: _..._- PERSON PERSON # PERSON CONTACTED: CONTACTED. ;CONTACTED: _.._.... .. .. .. ._ . i .. INSPECTOR: INSPECTOR: INSPECTOR: 2 DATE: DATE: 13 DATE VIOLATIONS VIOLATIONS PRE -CITATION CITATION ISSUED- 1 5 1 5 LETTER SENT NUMBER: t 4 CODE 5 2 6 2 6 DATE, _ SECTION RETURN RECEIPT 3 7 3 7 RECEIVED 6 DISPOSITION. 7 4 8 4 $ DATE LETTER NEEDED ❑ YES ❑ NO LETTER NEEDED ❑ YES ❑ NO 8 �7ti FIRE PREVENTION SNOHMISH CO. Serving Brier, Edmonds, and 12425 Meridian Ave S INSPECTION REPORT OEDMONDS Mountlake Terrace Everett, WA 98208 0 BRIER FIJLlb Phone (425) 551-1200 0 MOUNTLAKE TERRACE DISTRT www.FireDistrict].org Fax (425) 551-1272 [I UNINCORPORATED LOCATION: 7500 212 th Street SW Suite 108 98026 R BUSINESS NAME: esoQ-8�� 4255820078 PHONE: MAILING 7500 212th Street SW, Suite 108, Edmonds, WA 98026 ADDRESS: BUSINESS OWNER: Lowell, Howard HOME PHONE: EMERGENCY-1: Clay, Diana HOME PHONE: 0 KEYACCESS-2: HOME PHONE: EMAIL: PERSON CONTACTED: NAME OF INSPECTOR: Date Last Serviced: e' FRE 2017ENCY STfe& SHIFT SCHEDULED Dec 2016 DATE DUE � LIFIR CURRENT ' CITY YES , NO BUSINESS LICENSE 1�f 11 JIT17-INSPE)ON DATE I >,-, / T- F" � klz' ^r- --c- -�a - s ,y`,.�,.sr)"�-r,Y.. •s r.-�(, <r. \ FIRE .PREVENTION S sroiotsx co'N, Serving Brier, Edrnonds, and 12425 Meridian Ave S INSPECTION REPORT n�. ; FIRE; EDMO Mountlake Terrace Everett, WA 98208 ❑BR ERNDS IDISTR T Phone (425) 551-1200 ❑ UNINCOMOUNTRPORATED AKE TERRACE www.FireDistrictl.org Fax (425) 551-1272 ❑UNINCORPORATED FREQ ENCY STA SHIFT LOCATION; 7500 212 th Street SW Suite 109 98026 201 �-�& 4257441679 SCHEDULED Dec 2016 BUSINESS NAME: PHONE: DATE DUE ► c/V S 593 MAILING UFIR ► ADDRESS: 7500 212th Street SW, Suite 109, Edmonds, WA 98026 BUSINESS OWNER: HOME PHONE: EMERGENCY-1: Way, Suzanne HOME PHONE: 4257754648 CURRENT KEY ACCESS-2: HOME PHONE: CITY YES NO El BUSINESS EMAIL: LICENSE ❑ INITIAL INSPECTION DATE PERSON CONTACTED: NAME OF INSPECTOR: (��-`Gejy� L� t 3 / =IRE S S FE`.-g- /( 11 Date Last Serviced: HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS i 2 CvM,'tj 2 I. 4 4 r 5 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 FINAL RE -INSPECTION ! EXTENSION VIOLATIONS DATE DUE' DATE DUE: GRANTEDTO: ;DATE DUE: ! CITED: PERSON PERSON CONTACTED: CONTACTED: I PERSON 1 CONTACTED' E ` (2 INSPECTOR: INSPECTOR: INSPECTOR: DATE: DATE: €DATE: ` 3 VIOLATIONS VIOLATIONS PRE -CITATION CITATION ISSUED i 1 , 5 1 5 LETTER SENT NUMBER 4 .. CODE _ 5 .. .. 2 - 6 2 - 6 DATE SECTION RETURN RECEIPT _ 3 7 3 ' 7 RECEIVED 6 . DISPOSITION 4 ` 8 4 : 8 DATE. LETTER NEEDED ❑ YES ❑ NO LETTER NEEDED ❑ YES ❑ NO €8 SNOHOMISH CO. Serving Brier, Edmonds i ` P -� 1 1 i� 1 FIRE SYSTEMS: v PERSON CONTACTED: NAME OF INSPECTOR: FIREMountlake DISTRI Terrace,and tl�'IT w the Town of Woodway wwFireDistrictl. org �I LOCATION: 7500 �2tI7-�itEel'.i � BUSINESS NAME: Gent Components Inc. MAILING 7500 21 2$h StSW(I (� ADDRESS: Edmonds � BUSINESS OWNER: Gent, AiYli?fett$ � EMERGENCY-1: KEY ACCESS-2: 12425 Meridian Ave S Everett, WA 98208 Phone (425) 551-1200 Fax (425) 551-1272 SOU 107 PHONE: 4257753504 95026 HOME PHONE: 2063619964 HOME PHONE: HOME PHONE: FIRE PREVENTION INSPECTION REPORT ❑ EDMONDS ❑ BRIER ❑ WOODWAY ❑ MOUNTLAKE TERRACE ❑ UNINCORPORATED FREQUENCY STATION & SHIFT 730 16 O SCHEDULED DATE DUE / 12/01/11 UFIR ► 591 1 a157 ACTIVE CURRENT CITY YES NO BUSINESS 9— LICENSE INITIAL INSPECTION DATE FE _!_ ANNUAL HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS 1 1 Uhl 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 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 a 4 8 4 8 DATE: DISPOSITION: LETTER NEEDED ❑ YES ❑ NO LETTER NEEDED ❑ YES ❑ NO s FIRE DEPARTMENT COPY FIRE PREVENTION Ses-ving Brier; Edmonds 12425 Meridian Ave S INSPECTION REPORT SNOHOMISH CO. Mountlake Terrace,and F R Everett, WA 98208 ❑BRIER S ❑BRIER DISTRI the Town'of Woodivay Phone (425) SSI -1200 ❑ MO NT AY -❑ MOUNTLAKE TERRACE wwwFIreDlstrictl. org Fay (425) 551-1272 ❑ UNINCORPORATED LOCATION: 7500 212th St SAI 108 FREQUENCY 730 STATION & SHIFT 16 D BUSINESS NAME: Tracey L. Yost, UAP, LE - PHONE: 4259673824• SCHEDULED DATE DUE 12/G1/`71 MAILING 7500 212th St SW #106 UFIR ► 593 1;157 ADDRESS: Edmonds 98026 .4i BUSINESS OWNER: Yost, Tracey L. HOME PHONE: 4259673824 EMERGENCY-1: Green, Debbie �257761234 HOME PHONE: CURRENT KEY ACCESS-2: HOME PHONE: CITY YES NO BUSINESS El El LICENSE PERSON CONTACTED: INITIAL INSPECTION DATE NAME OF INSPECTOR: y FIRE_ FE I I SYSTEMS: ®, ANNUAL HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS 1 1 2 !` 2 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: I INSPECTOR: INSPECTOR: V 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 4 S 4 8 DATE: DISPOSITION: 7 LETTER NEEDED ❑ YES ❑ NO LETTER NEEDED ❑ YES ❑ NO 8 FIRE DEPARTMENT COPY FIRE PREVENTION Serving Brier; Edrrtortds 12425 Meridian Ave S INSPECTION REPORT SNOHOMISH CO. Mountlake Terraceand E Everett, WA 98208 BRIER S EDMOTIR ❑BRIER DISTAMT the Town of Wood vay FireDistrict]. Phone (425) 551-1200 AY ❑ M O MOUNT ❑ MOUNTLAKE TERRACE www org Fax (425) 551-1272 ❑ UNINCORPORATED LOCATION: 7500 212th Street 1 SW 109 FREQUENCY I STATION & SHIFT 7331 16 D j BUSINESS NAME: Mills, Donald H. DDSS PHONE: 4257785285 DATE DUE SCHEDULED► 12101f11 MAILING, 7500 212th St SW UFIR ► 593 1A57 ADDRESS: Edmonds 93026 BUSINESS OWNER: Wills, Donald fi o HOME PHONE: 4257741688 ACTIVE J EMERGENCY-1: HOME PHONE: CURRENT KEY ACCESS-2: HOME PHONE: CITY YES NO BUSINESS 0 11 LICENSE PERSON CONTACTED: INITIAL INSPECTION DATE NAME OF INSPECTOR:t, h1 yr u FIRE E f SYSTEMS: ANNUAL HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS 1 1 V 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 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 B FIRE DEPARTMENT COPY CITY OF EDMONDS ��jl!�' BUSINESS LICENSE APPLICATION — COMM ❑ Building ❑ Engineering FEE: $125.00 B 2 5 2016 ❑ Fire CITY CLERK'S OFFICE, BUSINESS LICENSE DIVISIM ❑ Punning Gt Police 121 5T" AVENUE NORTH, EDMONDS, WA 98020 PHONE 425.775.2525fflft r , 111 TM OFFICE USE ONLY BL# Customer # 3�J SIC I Year Class I SHD co Date Paid 20I TR# Fee t2g� Mailed Deleted INSTRUCTIONS: Please complete the application in full and attach the required floor plan. Middle Initial or name required of all parties concerned. If no middle name, please indicate by writing NMN. Sign and return application with fee. Please advise of any change in status. New license required if business changes location or ownership. Notification to City of Edmonds required if business closes. License expires December 31" each year. Renewal must be submitted prior to �January `�" 331" to avoid late fees. / / BUSINESS NAME �5C 5 Vl� �L BUSINESS ADDRESS --7SOD ���7— -JI e Sty W108 AMNd s MAILING ADDRESS 50 aIL3:t�. Q /O1 /!W/(.dLJ W4 C&a� Q Strcet oorrPPO Box #—TSuite N City. State. Zip Code BUSINESS PHONE(t4d- � } 5ga 7 9 WA STATE TAX ID # (UBIj Q D O 7 BUSINESS BUSINESS 4 Name / Phone Number // PROPERTY OWNER / 5DO 6114A. L-L C (qd 5 1 -7Aa - 03 y Name Phone Number EMERGENCY NOTIFICATION (For Premise Access in j Name _a l�ISY.P LQ- /-+n� /A P�?55 i Name hone Number LI " Last Name First Name MI Phone Number NATURE OF BUSINESS (Provide a Detailed Description of Business Activities, Products & E o t o 104 u (:�o AAIftD c n-P Y-,eDYYn-Vtf 13 �-- SPACE ALTERATIONS TO BE MADE: PREVIOUS BUSINESS AT THIS ADDRESS Q NUMBER OF EMPLOYEES_ SgPIAREaF AGE OF BU$INESS'SPACE r P.ROPOSEDiO_P,ENINGDATE-1� TYPE OF BUSINESS — PLEASE CHECK APPROPRIATE CATEGORY: ", ❑ CONSTRUCTION BUSINESS HOURS: �C�1�t4J�K�� AC15r%1�� ❑ FINANCE, INSURANCE, REAL ESTATE �� ❑ LANDSCAPE. HORTICULTURAL DAYS OPEN: (' vV Sit-+ �,1(ve.Ca UJtJG ❑ MANUFACTURING ❑ NON-PROFIT ❑ SUNDAY ❑ WEDNESDAY ❑ RETAIL ❑ ❑ SECONDHAND DEALER MONDAY ❑ THURSDAY rt SERVICES ❑ TUESDAY ❑ FRIDAY ❑ WHOLESALE ❑ SATURDAY ❑ OTHER l AMUSEMENT DEVICES ON PREMISES? YES NOA—IF YES, TOTAL NUMBER LIQUOR SOLD ON PREMISES? YES-- NO.X_ l GAMBLING? YES_ NO_2r CIGARETTES SOLD ON PREMISES? YES NO X FLAMMABLE OR HAZARDOUS MATERIALS USED OR STORED? YES NO,�''ttIF YES, PLEASE PROVIDE A LIST OF MATERIALS AND QUANTITIES: PARKING SPACES ON SITE: TOTAL SPACES�Ia ACCESSIBLE SPACES FOR HANDICAP PARKING kR-5 DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? YES NO a PARTNERSHIP — PARTNER 1 NAME FIRST MIDDLE INITIAL ADDRESS STREET SOITHAF?NNRi C CODE HONEPHGNH. UCENSEORIOC85TAT DATE OF BIRTI CRYSTAM OF NRTH COUNTRY OF 011 ARTNERSHIP—PA 2 LAST FIRST NE INITIAL ADDRESS SIRE SUITEIAPTIUNITN CITVSTA E NONE PH DRIVERS LICENSE OR 10 N B STAT TE OF BIRTH CITYISTArE OF BIRTH COUNTRY OF BIRTH SbeY $CVOITARAPpOc RATIONWLLIC �or Lr�LN/C NAM OFCOPORATICN,9ESC,O, SOMAl0s cr1s F�E✓D9ERTIAiLLTr{JAXr'O113i" CORPMORESS TI7±500 ?lXM CT J UP(- �f'�iSI�iT'SO1�CJOp Ql Gry, BMW Mb Z4 Code Phone Number CORPORATE_OFFICERR& eyel f;l"�f(1rC�Jr,�/I///./fZ 01:1i11II-II//t eL p�Ay/��he� r��1It��/� 26//g LOCALCONTACT1 „ LVI Z) L�L/�L{tI I F- Ilr'T/I1//f Qb5i LTP IM waw Prat Name w The C"dwee Dmm�.Ixasa or Gmer DNlsm Phones Numb OW USE MLY: BUILDING DEPT. APPROVE 0 DRAPPROVE DATE EII OCCUPANT LDAD BUILDING PERMIT OCCUPANCY ENGINEERING Q APPROVE O DISAPPROVE MTE SIGNATURE FIRE DEPT. APPROVE 0 DISAPPROVE DATE NGNATURE PLANWNG GEPT. Q APPROVE O DISAPPROVE ZONING CODE CONDRIONAL USE PER POLICE DEPT. O APPROVE 0 DISAPPROVE Suite 108 420 SY 7500 Building LYNNWOOD, WASHINGTON Partners 4DWp&V4 FROJECT: 1500 BUFLDI.r LOCATION: EDI}p�Og, y)gry.UTOI .OdTEi �'EN'1$ER.73,_70!0 sif 3 goo e Z(3 r S 7 CITY OF EDMONDS BUSINESS LICENSE APPLICATION- COMMERCIAL FEE: $125.00 CITY CLERICS OFFICE, BUSINESS'LICENSE DIVISION j"�•ls9° 121 5' AVENUE NORTH, EDMONDS, WA 98020 PHONE: 425.775.2525 OFFICE USE ONLY BLi! LCustomer# SIC Year Class SHD to Paid TR# Fee Paid Mailed Delete 0 0 / .3 `f aV-.C3 cZQ 0-0WJ S Od 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 /II • L S N A` L "A, C61\jt 5 -• 4+� BUSINESSADDRESS 7500 212.; " ST -sw. SAC 101_ q9b2.6 Suite No. •Zip Code MAILING ADDRESS 2�Z S'r �i O 1 OD/)' OOyu J,/* V026 Street or PO Box Suite No. City, State and Zip Code BUSINESS PHONE NO. ZS _ 7+ f 1671 WA STATE TAX IP NO. (UBI NO.) �- 01 J 11 Q �!' L BUSINESS E­1AAlL �it'InlLl�(� Vt�CWIS YI�CGI �Y� ✓.(.0I'�USINESS WEBSITE y 1-�ct I1 S n �'GilCt?-vl fed GUl� PROPERTY OWNER CLAY 1i�i2-i'21S Es, LJ C ( 4Z9 ) % 76 — .1'2-?�4 Name Phone Number EMERGENCY NOTIFICATION (For Premise Aooess In Emergency): wMlY NATNATI ' - G. 12a ) •7f 9._g, 9 t'ceul_ Last Name First Name MI Phone No. (+�S ) 7(al -4757 Cc fl Last Name First Name MI Phone No. NATURE OF BUSINESS PR.o F E SS i Q t�J/1 l tit C!bl �'L 4din/ NUMBER OF EMPLOYEES SQUARE FOOTAGE OF BUSINESS SPACE TYPE OF BUSINESS - PLEASE CHECK -THE APPROPRIATE CATEGORY: O CONSTRUCTION • d FINANCE; INSURANCE, REAL ESTATE. O LANDSCAPE, HORTICULTURAL O MANUFACTURING O NON-PROFIT .O RETAIL O SECONDHAND DEALER XSERVICES O WHOLESALE Cl OTHER AMUSEMENT DEVICES'ON•PREMISES? .d YES >. NO • IF YES, TOTAL NUMBER LIQUOR SOLD ON PREMISES?: O YES. �SN6 . - GAMBLING? O YES XNO . CIGARETTES SOLD ON PREMISES? O YES )(NO FLAMMABLE OR HAZARDOUS MATERIALS USED OR STORED?: O YES>(NO IFYES,-PLEASE PROVIDE UST OF MATERIALS AND QUANTITIES: PROPOSED OPENING DAY OF BUSINESS _ � ICJ ?-��3 BUSINESS HOURS o DAYS OPEN O SUNDAY '0$40ND,�Y )KJUESDAY _l.WEDNESDAY )KTHUR$DAY O FRIDAY *SATURDAY PARIgNG SPACES ON SITE: TOTAL MULTI PIS ACCESSIBLE FOR PERSONS WITH DISABILITIES YGS T' DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? )(YES O NO PREVIOUS BUSINESSUSE AT THIS ADDRESS Dc7�iTlSI Y�-V BOIEPITDMIEfDRBXP MANSE WAX 5u2At.)tir E- m is" 1:)CO MI sr SW LyAlNwcoD t.Wft gAb36 bheel pPL Nn..INfb. nl: y,. W PIWNENO.(AL51%%S 4(04.P OBI.NO. pIPNERE LIDEIdENOJ OROTHERm No )ATE OF BHITH-wl*�CITYANU STATE OF BMTTH SEMP—GT LA/n17HMY.TLvJ COUNTRY OF BIRTH U.S.A. PARINp19NIP • PMINER 1 NAME I®1 RM M ADDRESS 54 t ATa. NR..UMINe. CM.SNbenCilp Cotle HOLE PHONE ND.1.__ ) DOL W. (DRNERS LICENBEW.)CROTHER ONQ DATE OE BIRM GIYANDSTRTEOFBFON GOURRV OFBIRM . . IPRMERBHP.PMINFIIS .. NAME Isar AP W. ADDRESS Se fl APl N0.,UMND (yY. SIMeaMDR f:oOe HOME PHONE N(L-). Daw. B1RN LX6&Wj(1R O JDN61 ogre aFeiRrN cm Axo srgTEDF aiRT1 calnmTr'wwRm NAMEOFCORPORAT1ON CORD_ ADDRESS cmPaRRnaH . �TA%B)NO. PHONE NO(_I Slreel Cg PIXUTEOFFICEAS. LWNPM &YB. F{t:ONINN :Bbb FO{$Ip (:oy ' - Firtl Name NI Ttl¢ Oetto/&1N WLNO. (OMan Q'eiue Nwlw01MFID Na., I MNTACT f 1 La1NNm mm HoRN MI. m PMIn NB DMNu.IMi V&W)crODNrmN 7 L11- y �( (-P?/ -F � ©� �� , 3 6-� d1vS �s CITY OF EDMONDS BUSINESS LICENSE APPLICATION- COMMERCIAL FEE: $125.00 CITY CLERK'S OFFICE, BUSINESS LICENSE DIVISION /nc, 1a9� 121 5"" AVENUE NORTH, EDMONDS, WA 98020 PHONE: 425.775.2525 OFFICE USE ONLY BL# Custom er3 5 T IMIDLO_ Year Class SHD Date Paid ( 1 TE _ 7 ptQ Fee Pald 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 required if business changes location or ownership. Notification to City of Edmonds required if business closes. BUSINESS NAME BUSINESS ADDRESS Street MAILING ADDRESS L. Yoh No. Zip Code � Street or PO Box Z Q Suite No. City, State and �Zip Code BUSINESS PHONE NO. t--!� ) O/ o�f WA STATE TAX ID NO. (UBI NO.) BUSINESS E-MAIL UG•(0! Gt-O� • �i 3�'�I BUSINESS WEBSITE N PROPERTY OWNER L, L-49T7 PK-i3e!5 7W, I p �3 V Name Phone Number EMERGENCY NOTIFICATION (For Premise Access in Emergency): Last Name Last Name First Name Mi Phone No. NATURE OF BUSINESS EOM NUMBER OF EMPLOYEES SQUARE FOOTAGE OF BUSINESS SPACE EN Sih & , TYPE OF BUSINESS - PLEASE CHECK THE APPROPRIATE CATEGORY: S) ❑ CONSTRUCTION O FINANCE, INSURANCE, REAL ESTATE O LANDSCAPE, HORTICULTURAL O MANUFACTURING O NON-PROFIT O RETAIL O SECONDHAND DEALER rERVICES AMUSEMENT DEVICES ON PREMISES? O YES *NO O WHOLESALE O OTHER IF YES, TOTAL NUMBER LIQUOR SOLD ON PREMISES?: D YES )9 NO GAMBLING? O YES �j NO CIGARETTES SOLD ON PREMISES? O YES C)WO FLAMMABLE OR HAZARDOUS MATERIALS USED OR STORED?: O YES IF YES, PLEASE PROVIDE LIST OF MATERIALS AND QUANTITIES: PROPOSED OPENING DAY OF BUSINESS S� `� BUSINESS HOURS DAYS OPEN O SUNDAY MONDAY T ESDAY }9 WEDNESDAY >g�THURSDAY fill FRIDAY WSATURDAY PARKING SPACES ON SITE: TOTAL 1 r ACCESSIBLE FOR PERSONS WITH DISABILITIES DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? WYES O NO PREVIOUS BUSINESS USE AT THIS ADDRESS mo-t .5 V -t— NAME �°�ST i-1 L84 MI MI Iftm mac 5mI to qg"t Avio U) • T,ria HOME PHONE NO.. AzL G�-38ay00L NO.IDRW�ER�S U�C�E/NEE N0.)OROTHER LL)NO._® DATEOFBIRTH1� a y'�.�GIY ANO STATE OF BIRTH SY.ANT YC4 LV COUNTRY PARTNERSIIIP •PARTNER T NAME Law Rat MI ADDRESS Strew ApL No.. UM No. City. State and Zip Edda HOME PHONE NOI 1 DCL NO, (ORDERS LICENSE NO.) OR OTHER O NO. DATE OF BIRTH Qtt AND STATE OF BIRM GOIMRV OF BIRTH PARTNERSHIP•13ARTNER2 NWE Lai Rlat MI ADORE$$ Slmw Ail Na.. Unit No. City. State and! Zip Cole HOMEPHONENO(J CO. NO. (ORDERS LICENSE NO.) OR OTHER ID NO. UATEOFBIRTH CTANDSTATEOFEURTH COUMRVOFBIRTH NAME OF CORPORATION CORP. ADDRESS Street CORPORATE OFFICERS: Land Name CONFORPORON FEDERAL TAX ID NO. PHONE NO �1 Suit. Apt, Unit Na Ory. Stalo and Zip Code FININaIm MI Ttlt Ueleo(Biral COL Nm OdaeN Ucenm No.) ar Ot4 ID No. LOCALCONTACT ( 1 Wt Name mm Nxnm MI Me FM1ure No. DOLN0.(DU4ULi0.N0.)or Olner IDNo. gall Irrr C USE ONLY: PLANNINGDEPT. OAPPRii ODISAPPROVE DATE SIGNATURE ZONING CODE CONDITIONALUN E PERMD COMMENTS BUILDINGOEPT. OAPROJE ODISAPPROVE DATE SIGNATURE OCCUPANTLOAD SUILDINGFEWIT OCCUPANCY GROUP COMMENTS FIRE DEPT. OAPPROVE ❑DISAPPROVE DATE SIGNATURE U.F.I.R. COMMENTS PONCE DEPT. COMMENTS OAPPROVE ODISAPPROVE DATE SIGNATURE ip 13'-I 3/4° Suite 108 420 S.F. 7500 Building I - LYNNWOOD, WASHINGTON L - M7-, P, L- L Partners PROJECT: IWO BUILDING LOCATION; EDMONDS, WASWINGTON DATE, NOVEMBER 23, 2010