120 W DAYTON ST STE C2SkOHOAIISH Co.
FIRE
DIS'T:
fit,CZ
-FIRE PREVENTION
Serving Brier, hamonds, and 12425 Meridian Ave S INSPECTION REPORT
�EDMONDS
Mountlake Terrace Everett, WA 98208 BRIER
Phone (425) 551-1200 0 MOUNTLAKE TERRACE
Twww.FireDistrict].org Fax (425) 551-1272 0 UNINCORPORATED
LOCATION: 120 West Dayon Street Suite C2 98020
BUSINESS NAME: Harbor, Square Dental
PHONE: 4257787477
MAILING
ADDRESS: 120 West Dayton Street, Suite C2, Edmonds, WA 98020
FREQUENCY I STATION& SHIFT
2017 17-B
SCHEDULED Sep 2017
DATE DUE ►
UFIR / 591
BUSINESS OWNER:
PA �'7' A
I HOME PHONE: - I 4/ 3 - c — 41- 7
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EMERGENCY-1:
HOME PHONE:
CURRENT
KEY ACCESS-2:
EMAIL: PK'l C
HOME PHONE: 17
CITY
BUSINESS
YES NO
57e
LICENSE
PERSON CONTACTED:
/v
INITIAL INSPECTION DATE
NAME OF INSPECTOR:
0 - 41P- -
FIRE SYSTEMS: FEjD /4
Date Last Serviced:
')� ( Sefvin Brier, Edrnonds
' SNOHOMISH CO. g
FIREI, 1�1
11`Mozintlake7,Terrace,and „
the Town of Woodway
DISTItIrT www.FireDistrictl.org
LOCATION: 120 W_ Dayton Street
j BUSINESS NAME: Harbor Square Dental
MAILING 120 W. Dayton St #C2
ADDRESS: Edmonds
BUSINESS OWNER:
Serra, Nicole
EMERGENCY-1: Conner, Jan
KEY ACCESS-2:
I PERSON CONTACTED:
NAME OF INSPECTOR:
FIRE
SYSTEMS:
12425 Meridian Ave S
Everett, WA 98 208
Phone (425) 551-1200 "
Fax (425) 551-1272
C2
PHONE: 4257787477
98020
HOME PHONE: 2063494711
HOME PHONE: 4257741511
HOME PHONE:
FIRE PREVENTION
INSPECTION REPORT
❑ EDMONDS
❑ BRIER y
❑ WOODWAY
❑ MOUNTLAKE TERRACE
❑ UNINCORPORATED
FREQUENCY
STATION & SHIFT
365
I
'17 D
CHEDULED 09%01
ATE DUE 11
FIR ► 593
9202
ACTIVE
CURRENT
CITY YES
NO
BUSINESS
LICENSE
INITIAL INSPECTION DATE
FE —t -
ANNUAL
HAZARDS FOUND AND LOCATIONS / COMMUNQATIONS
1
1
2
2 i
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3
3
4
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4
5
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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:
GRANTED TO:
DATE DUE:
CITED:
PERSON
PERSON
PERSON
CONTACTED:
CONTACTED:
CONTACTED:
'
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
VIOLATIONS
PRE -CITATION
CITATION ISSUED
1 5
1 5
LETTER SENT
NUMBER:
4
CODE
5
2
6
2
6
DATE:
SECTION:
RETURN RECEIPT
3
7
3
7
RECEIVED
a
DISPOSITION:
fJ
/
7
4
8
l,"
4
8
DATE:
LETTER NEEDED ❑ YES ❑ NO
LETTER NEEDED ❑ YES ❑ NO
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FIRE DEPARTMENT COPY