107 5TH AVE N STE 103SNO)
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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:107 5 th Avenue N Suite 103 98020
BUSINESS NAME: Rusty Pelican Cafe PHONE: 4252
Ce,l-P4
MAILING
ADDRESS:107 5th Avenue N, Suite 103, Edmonds, WA 98020
BUSINESS OWNER: HOME PHONE:
FIRE PREVENTION
INSPECTION REPORT
KEDMONDS
((]] BRIER
❑ MOUNTLAKE TERRACE
❑ UNINCORPORATED
FREQUENCY STATION & SHIFT
Annual 17-B
SCHEDULED
DATE DUE ► Feb 2018
UFIR � 161 203
EMERGENCY-1:LinlberopouloS, Marilyn HOME PHONE: 4253495628 CURRENT YES NO
KEY ACCESS-2: HOME PHONE: 17 CITY
BUSINESS
EMAIL: LICENSE
PERSON CONTACTED: `\ f, �Afj,,Cj INITIAL INSPECTION DATE
Q
NAME OF INSPECTOR:
FIRE SYSTEMS: FE 11/15 HD 4/15
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
3
3
4
4
5
—_
5
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6
7
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X 1
1st RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
,
/
l E NSIo
GRANTEDTO:
FIN RE-INSPECTIO
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
'
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3_
VIOLATIONS
1 5
VIOLATIONS
1 5
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER: 4
CODE 5
SECTION: _
2
6
2
6
DATE:
3
7
3
7
RETURN RECEIPT
RECEIVED
DATE:
DISPOSITION:
8
4
8
4
8
LETTER NEEDED ❑ YES ❑ NO
LETTER NEEDED ❑ YES CI NO,
J