123 2ND AVE S 1ST FLOOR123 Z tj0 iq vc J
:� '' CITY OF EDMONDS �! �' Fc o o R,
`_'� 1VIE4'�USINESS LICENSE APPLICATION — COMMERCIAL ❑ Building
❑ Engines"
FEE: $125.00 ❑ Fire
JAN 19 2011 CITY CLERK'S OFFICE, BUSINESS LICENSE DIVISION ❑ Planning
121 5TH AVENUE NORTH, EDMONDS, WA 98020 PHONE 425.775.2525 ❑ Police
DMOM• , OFFICE USE ONLY
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Class
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Date 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. License expires December 31" each year. Renewal
must be submitted prior to January 31" to avoid late fees.
BUSINESS
BUSINESS ADDRESS �� > ' 2 Ite- /7, L' e, .S f
Street Suite #
City, State,
MAILING ADDRESS Sri /1,7 e,
/ Street or PO Box # Suite # City, Slate, Zip Code
BUSINESS PHONE G } 7 / Z`/� WWA STATE TAX ID # (UBI) �j O �_ I o o /' _ -c
BUSINESS E-MAIL-- a<� r C!f?��175 L� BUSINESS WEBSITE//,//f`6e.l�Gj��I7!' [ I", Sr1 ;�.C/J?.�1
BUSINESS OWNER/MAIN CONTACT-16�t6I'ij
Phone Number
PROPERTY OWNER
Name Phone Number
EMERGENCY NOTIFICATION (For Premise Access in Emergency): r_ /
�/G e ti �i/l �� r'�.� r
Last Name First Name MI Phone Number
Last Name First Name MI Phone Number
NATURE OF BUSINESS (Provide a Detailed Description of Business Activities, Products & Services):
SPACE ALTERATIONS TO BE MADE:
PREVIOUS BUSINESS AT THIS ADDRESS
NUMBER OF EMPLOYEES iT 7 SQUARE FOOTAGE OF BUSINESS SPACE_ S �7
TYPE OF BUSINESS - PLEASE CHECK APPROPRIATE CATEGORY:
❑
CONSTRUCTION
❑
FINANCE, INSURANCE, REAL ESTATE
❑
LANDSCAPE, HORTICULTURAL
❑
MANUFACTURING
❑
NON-PROFIT
❑
RETAIL
❑
SECONDHAND DEALER
SERVICES
❑
WHOLESALE
Cl
OTHER
PROPOSED OPENING DATE: y? /i heir
BUSINESS HOURS:I.7
DAYS OPEN:
*S WN@ a-*EDNESDAY
B-MONDAY LdrfHURSDAY
d-4ESDAY Q'FRIDAY p(GQS/�N�I
AMUSEMENT DEVICES ON PREMISES? YES NO Z IF YES, TOTAL NUMBER LIQUOR SOLD ON PREMISES? YES NO
GAMBLING? YES_ NO CIGARETTES SOLD ON PREMISES? YES NO
FLAMMABLE OR HAZARDOUS MATERIALS USED OR STORED? YES NjO IF YES, PLEASE PROVIDE A LIST OF MATERIALS AND QUANTITIES:
A-o /%`vr % Q/ ii /9 id -y- ��i/ 2—e7er 2'x r�7P�. �•
i
PARKING SPACES ON SITE: TOTAL SPACES_ ACCESSIBLE SPACES FOR HANDICAP PARKING
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? YES--j,--- NO
NAME 1"I�z7uei.J SE/ "4/-)s
Printed Name &
TITLE_ PQl ns �� %i�DS tt�r3r7 DATE �Z_11C_/ �q�'zA
`L
1�
le
SOLE PROPRIETORSHIP
NAME
LAST FIRST MIDDLE INITIAL
ADDRESS
STREET SUITE/APT/UNIT # CITY/STATE171P CODE
HOME PHONE( 1 DRIVERS LICENSE OR ID # & STATE
DATE OF BIRTH CITY/STATE OF BIRTH COUNTRY OF BIRTH
NAME
ADDRESS LAST FIRST MIDDLE INITIAL
STREET SUITE/APT/UNIT # CITY/STATE/ZIP CODE
HOME PHONE( 1 DRIVERS LICENSE OR ID # & STATE
DATE OF BIRTH CITYISTATE OF BIRTH COUNTRY OF BIRTH
PARTNERSHIP - PARTNER 2
NAME
ADDRESS LAST FIRST MIDDLE INITIAL
STREET SUITE/APT/UNIT # CITY/STATEIZIP CODE
HOME PHONE( 1 DRIVER'S LICENSE OR ID # & STATE
CORPORATION/ LLC or PLLC
NAME OFCORPORATION.
New I. lj L' C=
C/5 I!' � I.) � �O L �- �— FEDERALTAX D#
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CORP.ADDRESS I4 3
2ItC> lt.,,e
#//0 ��l7:'�°fC�S, fit'/ 4/��l�G
Street
SuHe, Apt. Unit # City, State and Zlp Code
Phone Number
CORPORATE OFFICERS:
Last Name First Name
As -C Zirr� >�r
MI Title DateolBkth Driver License or Othor D#/State
to a .t:zr'i Z,f��/77 9�e'YIS;�'N>v 2 3 (0C,,�
LOCAL CONTACT
�� /1•LC _—.
Last Name
First Name
MI Tide DateofBlrlh
Drivers License or Other D#/State
Phone Number
CITY USE ONLY:
BUILDING DEPT. 0 APPROVE 0 DISAPPROVE DATE SIGNATURE
OCCUPANT LOAD BUILDING PERMIT
OCCUPANCY GROUP
COMMENTS
ENGINEERING M APPROVE DISAPPROVE DATE SIGNATURE
FIRE DEPT. O APPROVE DISAPPROVE DATE SIGNATURE
COMMENTS
PLANNING DEPT. 0 APPROVE Q DISAPPROVE DATE SIGNATURE
ZONING CODE _ CONDITIONAL USE PERMIT,
COMMENTS
POLICE DEPT. 0 APPROVE Q DISAPPROVE DATE SIGNATURE
COMMENTS
a
T
i--------------------------------- ----------------------------------------------------------
1
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JAN 19 2017
EDMOiVDS Cl'fY CLERK ; �!
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' A Partition Legend: , r
EXISTING PARTITION/CONSTRUCTION i 1 11 l
TO REMAIN I I II 11
NEW EXTENDED GRID -HEIGHT I I if
PARTITION
g a NEW FIRE -RATED PARTITION /= Floor _Plan
® NEW PLUMBING PARTITION
JPC ARCHITECTS Space Plan LRRAMSY CB
joe NO: 15-0M
Affinity Dentistry OATEi 01.09.16
wf.�
Flow 1 Rev 2
0 2015. JPC ARCHITECTS VLLC
►tee.- �
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SNOiiONTIST3 CO. .� '". ; Serving Brier, Edmonds, and
FIREMountlake Terrace
DISTRT www.FireDistrictl.org
LOCATION: 123 2 nd Avenue S Suite 130 98020
BUSINESS NAME: Fortaleza WL LLC
MAILING
ADDRESS: 333 Greystone Dr, Walla Walla, WA 99360
BUSINESS OWNER: Shulman, Judith
EMERGENCY-1: Frisk, Sheryl
KEY ACCESS-2:
EMAIL:
PERSON CONTACTED:
NAME OF INSPECTOR:
it
FIRE SYSTEMS 4 , - "•'.y ,
12425 Meridian Ave S
Everett, WA 98208
Phone (425) 551-1200
Fax (425) 551-1272
PHONE: 2069098054
FIRE PREVENTION
INSPECTION REPORT
❑ EDMONDS
❑ BRIER -
❑ MOUNTLAKE TERRACE
❑ UNINCORPORATED
FREQUENCY STATION & SHIFT
2014 17-A
SCHEDULED
DATE DUE ► Dec 2015
UFIR ► 891 202
HOME PHONE:
HOME PHONE: 2066121610. CURRENT
HOME PHONE:
CITY YES
NO
'BUSINESS
LICENSE r
INITIAL INSPECTION DATE
ti r
HAZARDS FOUND{AND LOCATIONS / COMMUNICATIONS'
2 , ;
{
2
3
l .l
a
3.
�f
4
4
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
EXTENSION
FINAL RE -INSPECTION
VIOLATIONS
DATE DUE:
DATE DUE: _
GRANTED TO:
DATE DUE:
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
i
...„„„....,_�._ _._.._._................
CONTACTED:
INSPECTOR:
2
INSPECTOR:
INSPECTOR:
DATE:
DATE;
DATE:
3
VIOLATIONS
VIOLATIONS:,:
PRE -CITATION
CITATION ISSUED
1 5
1 5
LETTER SENT
NUMBER:
4
DATE:
_._.._
CODE .._
SECTION:
5 .
2 6
2 6
RETURN RECEIPT
3
7
3
7
RECEIVED
e
DISPOSITION:
4 18-.®.....:�-.
4 8
DATE:
LETTER NEEDED YES ❑ NO
❑
LETTER NEEDED ❑ YES ❑ NO
- T'
__�.............�_-�
__~. •���
8
GUARbiAN SECURIrY
0 DC
to 0 Silverdale 0 Bellingham
1
743 FirstAvenueSinith 9435 Provost Rd 0204 I601 Kentucky Street �-
Seattle,A S9134 Silverdale, WA 99383 Bellingham, WA 98222
1:800.252-6998 360392-3738 360.647.0110
Lir- # GUAROSS233K5 1-800-36:4005
Facility
Address
Building Owner
MAIN FIRE CONTROL
W-"&oner;06riW
2, No of Initiating Circuits
No. of
. 4 Battery Voltages Under Load w§ignal Devices operating:
Fire Department
CONFIDENCE TESTING
FIRE ALARM SYSTEM (CTF-8)
Date of Inspection
Semi -Annual . . 0
#2—#3 _ #4 -
NIA
Phone#
I I �:s C' No E] NIA EpWri:-
8. All Circuits Operate Satisfactory On AC Power,
,at
�.'Afj Circuits FdT'Elec 1^ upervisiorl--:
J,c
A,-.
10. Control Panel Checks Made Per Manufacturers Instructions :
Explain
h(Yes 0 No 0 NtA
11, Ali Auxiliary Equipment Operates
V Fan'ShVCdowA. 600"c10Sur6: 4� dampers. Etc .1:
;W
a
12 ibt Au�fjbt, SW
Yes: ExplafA:, f
13 Monitoring Station Alarm Circuit(s)
ar m.De layj,unctik ).0krates ..00 �t.!
NIA Explains)
Exptem
- -
15. Panel Key Available.
Yes 14 , A Exptalm
371
y Explain
_Q:OpgjalLng-.
17 Test/Service Record at Fire Alarm Control Panel:
ONo If no, where filed?
NO. OF UNITS
EQUIPMENT TYPE
NO. OF UNITS RESULTS
IN BUILDING'
TESTED W.
,'
' '6
Audio (Bells, Horns, Chimes, Voice Alarm Speakers}
-----------Yes No
Yes No
Audio/Visual Devices
es
`Smoke Del
Yes No
Heat Detectors
66...
Manual'Oul,Ssations:•
Trouble Indicators Yes No
Anrtuneiatgts,
Auto Door Unlocks (Fail Safe Operation) Yes No
Yes,
Yes No
Fire/Smoke* Dampers (Ventilation Controls)
Yes No
Firernans Phones Nt.. r"'.
es y
N.
Elevator Capture Phase #1 7
Yes
Yes No
Generator Starts
!,AutomAcLamYes No
Automatic Sprinkler Supervisory Switches C-2
No
otcimatic,Sprinkler VAve.AmperS+,ittches Yes No
Control Valve Supervisory Switches
No
gl;+:,;",:;,.
ExteriorViater.Wtor- el,/G*
e
on Yes No
Fire Department Monitoring
o
nit6inng Sla-tiomeceed gSi riall(i - iv' �A-
..
Name of Alarm Monitoring Company
This C rtifies It t this fir yste been properly inspected for reliability to cover the items listed in this report, is consistent with fire
a a t I an d- cies are ed and have been reported to the building Owner/Manager for corrective Action.
Signature of.. [h)pectorNchnicjan
Ignat (e of. Fa Owner Manager
-%x
Tecjhniclan Electrical License 9 .4--" Technician Certification 4
Problems Found: X
Correction
Date Corrected
By:
Rev, 06111102
f
GUARDIAN ®AN SECURITY �� e�;> Fire Department
Seattle ❑Sllverdale []Bellingham Lic.#GUARQSS233K5 CONFIDENCE TESTING
1743RWAvenuoSouth 94MftvostRd.#20a 1601Kentucky slreeet AUTOMATIC SPRINKLER SYSTEMS (CTF-4)
Seas. WA 98134 SRverdale, WA 98383 Bangham,WA98229
206-822-6545 360-692-3738 360-647.0110 Date of Inspection
1400-282-6998 s 1-800.466-1005r--
Address- 91 Building No.
Occupied as System No.
Building Owner Phone#
City State Zip Code
Address
Type of inspection: Annual D Other
DRY SYSTEM
1. Trip test (dry trip) conducted: System tripped in 40 seconds.
2. All flow switches, supervisory switch and alarm bells tested.
3. Alarm bell operates .
4. Flow tests conducted. Flow pressured psi .
5. Systems inspected and lubricated.
6. Air compressor refills system in 30 minutes.
7. System drained and restored to normal operation.
8. Were the heat actuation devices tested on pre -action
and deluge system.
WET SYSTEM
1. Flow test conducted. ❑ Yes ❑ No Static pressure psi
2. Flow switches, supervisory switches and alarm bells tested.
3. Alarm bell operates.
4. Systems inspected an/bricated.
5. Pressure regulating valves tested.
GENERAL
1. Location of sprinklers ❑ Basement ❑ Hallways ❑ 100%
2. Pumper connections and clapper unobstructed.
3. Sprinkler heads less than 50 years old.
4. Sprinkler coverage is acceptable.
5. Spare sprinkler heads are available.
6. Systems left in service.
7. Valves are sealed or supervised.
8. Signs are provided on valves.
Problems Found: Qr o__-A cs,�
Correction Made:
Date Corrected
By:
KYes D No
❑ N/AExplain:
[Wes O No
❑ WA Explain:
❑Yes ❑ No
[&N/AExplain:
XYes ❑ No
❑ N/A Explain:
6Yes ❑ No
D N/A Explain:
[*es D No
❑ N/A Explain:
dies ❑ No
D N/AExplain:
❑Yes ❑ No
I(N/AExplain:
Flow pressure psi. 2-inch drain? ❑ Yes ❑ No
❑Yes ❑ No
❑ Explain:
❑Yes O,N
N/AExplain:
❑Yes D No
❑ N/AExplain:
❑Yes D No
❑ N/AExplain:
D Other
les D No
❑ N/AExplain:
O§Yes ❑ No
❑ N/A Explain:
1lYes D No
❑ N/A Explain:
kYes ❑ No
❑ N/AExplain:
G(Yes ❑ No
❑ N/AExplain:
0((es ❑ No
❑ N/A Explain:
*es ❑ No
D N/A Explain:
This Certifies that this sprinkler system has been properly inspected for reliability to cover the items listed in this report, is
consistent with fire alarm maintenance standards, discrepancies are noted and have been reported to the building Owner/
Manager for corrective Act" n.
Signature of Tester: Certification No.
Rev. aW8
9. r nnf;ricn4in1"
GUARDIAN SECURITY_-'Z Fire Department
wSeattle []Silverdale ❑Bellingham Lie.#GUARDSS233K5 CONFIDENCE TESTING
1743PbstAvenueSouth 9435 Provost Rd. #204 1601xeat=WStresel AUTOMATIC SPRINKLER SYSTEMS(CTF-4)
Seattle, WA. 98134 Silverdale. WA 98383 Bellingham, WA 98229
206.822.6545 36t692.3738 360.647--0110 Date of Inspection �i : a z'k
14WO-282-6998 1-800 366-1005
Address t4� �
tr.- .A Building No.
Occupied as � 'Qo�
a ,z5,System No.
Building Owner _ Phone# (AC3 y
Address City State Zip Code
Type of inspection: X Annual ❑ Other
DRY SYSTEM
1. Trip test (dry trip) conducted: System tripped in seconds.
2. All flow switches, supervisory switch and alarm bells tested.
3. Alarm bell operates .
4. Flow tests conducted. Flow p sure Psi.
5. *Systems inspected and icated.
6. Air compressor refi system in 30 minutes.
7. System draine nd restored to normal operation.
8. Were the heat actuation devices tested on pre -action
and deluge system.
WET SYSTEM
1. Flow test conducted. VYes ❑ No Static pressured psi
2. Flow switches, supervisory switches and alarm bells tested.
3. Alarm bell operates.
4. Systems inspected and lubricated.
5. Pressure regulating valves tested.
GENERAL
1. Location of sprinklers ❑ Basement ❑ Hallways 100%
2. Pumper connections and clapper unobstructed.
3. Sprinkler heads less than 50 years old.
4. Sprinkler coverage is acceptable.
'5. Spare sprinkler heads are available.
6. Systems left in service.
7. Valves are sealed or supervised.
8. Signs are provided on valves. \
Problems Found: U,% ?:�-`� y ter*�� �'
Correction Made:
Date Corrected
By:
❑Yes ❑ No ❑ N/AExplain:
❑Yes ❑ No ❑ N/A Explain:
❑Yes ❑ No O N/AExplain: --
❑Yes ❑ No ❑ N/AExplain:
❑Yes ❑ No ❑ N/AExplain:
[--]Yes ❑ No ❑ N/A Ex n:
❑Yes ❑ No
❑ xplain:
❑Yes ❑ o
❑ N/AExplain:
Flow pressure I S psi. 2-inch drain? ❑ Yes *0
❑Yes ❑ No
❑ N/AExplain:
❑Yes ❑ No
❑ N/AExplain:
❑Yes ❑ No
❑ N/AExplain:
❑Yes ❑ No
❑ N/AExplain:
❑ Other
XYes ❑ No
❑ N/AExplain:
9,Yes ❑ No
❑ N/A Explain:
4Yes ❑ No
❑ N/AExplain:
Mes ❑ No
❑ N/AExplain:
k Yes ❑ No
❑ N/AExplain:
*es ❑ No
❑ N/AExplain:
[)kes ❑ No
❑ N/AExplain:
4
This Certifies that this sprinkler system has been properly inspected for reliability to cover the items listed in this report, is
consistent with fire alarm maintenance standards, discrepancies are noted and have been reported to the building Owner/
Manager for corrective Acti n.
Signature of Tester: Certification No.
Ray. sr3/g8
... _.-.-. o n_, r.,J....c;-l"
GUARDIAN SECURITY
Seattle
1743 First Avenue South
Seattle, WA 98134
206-622-6545
1-800-282-6998
❑ Silverdale
9435 Provost Rd. #204
Silverdale, WA 98383
360-692-3738
❑ Bellingham
1501 Kentucky Streeet
Bellingham, WA 98229
360-647-0110
1-800-366-1005
Baclfiow Prevention
Report (CTF-25)
Lic. # GUARDSS233KS
ASSEMBLY ID: PASSED ANNUAL TEST: YES O NO 0
NAME OF PREMISE �'� `"A' COMMERCIALI, RESIDENTIAL ❑
4A
SERVICE ADDRESS�`1;, 2 c . '_ ' �� CITY ay�R '�C :` STATE S ZIP
CONTACT
LOCATION OF ASSEMBLY GO-4
PHONE ) S�<--) FAX ( )
W
DOWNSTREAM PROCESS-_a�'ti��C" DCVAI RPBA O PVBA O OTHER:
NEW INSTALL O EXISTINGYQ REPLACMENT O OLD SER. # PROPER INSTALLATION? YES; NO 0
J�
MAKE OF ASSEMBLY ,y� ��i� MODEL 5 ,� SERIAL N0A1!abk55 SIZE 1
INITIAL
DCVA / RPBA
OCVA / RPBA
RPBA
PVBA / SVBA
TEST
CHECK VALVE NO. 1
CHECK VALVE NO.2
AIR INLET
OPENED AT PSID
LEAKED O
LEAKED 0
#1 CHECK PSID
OPENED
AT PSID
PASSED �
� � PSID
� �� PSID
FAILED O
AIR GAP OK?
DID NOT OPEN 0
NEW
CLEAN REPLACE PART
CLEAN REPLACE PART
CLEAN REPLACE PART
CHECK VALVE
PARTS
HELD AT PSID
AND
0 O
0 0
0
LEAKED O
REPAIRS
❑ 0
p ❑
0 O
CLEANED O
0 ❑
❑ O
D O
0 ❑
❑ ❑
0 0
REPAIRED O
TEST AFTER
REPAIRS
LEAKED O
LEAKED O
OPENED AT PSID
AIR INLET _. PSID
PASSED O
#1 CHECK PSID
CHECK VALVE
FAILED O
PSID
PSID
PSID
AIR GAP INSPE equired minimum air gap seperation provided? Yes ❑ No [1 Detector meter Reading
REMARKS;- LINE PRESSURE `.ate PSI
CONFINED SPACE?C
CERT. NO. Cs-7 DATE 20IS
TESTER NAME PRINTED ���`�- ,°`�`` ® TESTER PHONE # isJ `'
REPAIRED -BY:
FINAL TEST BY:
CERT. NO.
DATE
DATE
CALIBRATION DATE. GUAGE# __ MODEL SERVICE RESTORED? YES'. ] NO a
l certify4hat this report is accurate, and / have used WAC 246-290-490 approved test methods and test equipment.
"Orn r�ri e4ri rat n. ('llnfirlantlai"
GUARDIAN SECURITY
jaSeattie
1743 First Avenue South
Seattle, WA 98134
206-622-6545
f-800-282-6998
O.Silverdale
9435 Provost Rd. #204
Silverdale, WA 98383
360-692-3738
❑ Bellingham
1501 Kentucky Streeet
Bellingham, WA 98229
360-647-0110
1-800-366-1005
B ackflow Prevention
Report (CTF-25)
Lic. # GUARDSS233KS
ASSEMBLY ID: PASSED ANNUAL TEST: YES'Cil�NO O
NAME OF PREM
4z .� V-`.
COMMERCIAL RESIDENTIAL O
SERVICE ADDRESSCITY STATE` ZIP
?`.,
CONTACT PERSON___`_a�PHONE FAX
—
LOCATION OF ASSEMBLY
DOWNSTREAM PROCESS �3��`CC° DCVA RPBA ❑ PVBA O OTHER:
NEW INSTALL O EXISTING CREPLACMENT ❑ OLD SER. # PROPER INSTALLATION? YES X NO CI
MAKE OF ASSEMBLY U� ��`�`� MODEL �'_-)3 xL SERIAL NO. 93L SIZE '
INITIAL
DCVA I RPBA
DCVA / RPBA
RPBA
PVBA / SVBA
AIR INLET
TEST
CHECK VALVE NO. 1
CHECK VALVE NO.2
OPENED AT PSID
LEAKED O
LEAKED O
#1 CHECK PSID
:::
OPENED
AT PSID
PASSED
L ,_PSID
b`� PSID
AIR GAP OK?
DID NOT OPEN O
FAILED O
NEW
CLEAN REPLACE PART
CLEAN REPLACE PART
CLEAN REPLACE PART
CHECK VALVE
PARTS
HELD AT _PSID
AND
00
LEAKED 0
REPAIRS
0
O O
O 0
O O
0 0
0 0
CLEANED O
O O
O p
O O
REPAIRED O
TEST AFTER
REPAIRS
LEAKED ❑
LEAKED O
OPENED AT PSID
AIR INLET — PSID
PASSED O
#1 CHECK____ PSID
CHECK VALVE
FAILED O
PSID
PSID
PSID
AIR GAP INSPE iN: Requiir� minimum air gap seperation provided? Yes O No O Detector Meter Reading
_TuREMARKS:— C LINE PRESSURE 1 PSI
REMA
CONFINED SPACE?
TESTER SIGNATU
TESTER NAME PRINTED W\
REPAIRED -BY:
CERT. NO. 5 DATE v 0
J,--_Ak TESTER PHONE # &E� f oAq-
FINAL TEST BY: CERT. NO.
DATE
DATE
CALIBRATION DATE: 3 /v7 lV1k GUAGE# d g - MODEL ° t 5 SERVICE RESTORED? YES NO O.
I certifythat this report is accurate, and l have used WAC 246-290-490 approved test methods and test equipment.
"Drnnriatnni P. r.nnfidP.ntial"
GUARDIAN SECURITY
!Seattle ❑ Silverdale ❑ Bellingham
1743 First Avenue South 9435 Provost Rd. #204 1501 Kentucky Streeet
Seattle, WA 98134 Silverdale, WA 98383 Bellingham, WA 98229
206-622-6545 360-692-3738 360-647-0110
1-800-282-6998 1-800-366-1005
Bacidlow Prevention
Report (CTF-25)
Lic. # GUARDSS233KS
ASSEMBLY 1D: PASSED ANNUAL TEST: YES ❑ NO 0
NAME OF PREMISE COMMERCIAL RESIDENTIAL O
SERVICE ADDRESSc' sz� CITY STATE �-� SIP
CONTACT PERSON PHONE C,9�2 +'z } OtSOADPAFAX
LOCATION OF ASSEMBLY
DOWNSTREAM PROCESS DCVAtX RPBA ❑ PVBA O OTHER:
NEW INSTALL ❑ EXISTIN(N REPLACMENT ❑ OLD SER. # PROPER INSTALLATION? YES tKNO ❑
a 3A
MAKE OF ASSEMBLY MODEL _� SERIAL NO. Niw(S-13 SIZE
INITIAL
DCVA /RPBA
DCVA / RPBA
RPBA
PVBA / SVBA
TEST
CHECK VALVE NO. 1
CHECK VALVE NO.2
AIR INLET
OPENED AT PSID
LEAKED ❑
LEAKED O
OPENED
#1 CHECK PSID
AT PSID
PASSED &
- d PSID
�La PSID
FAILED ❑
AIR GAP OK?
DID NOT OPEN ❑
NEW
CLEAN REPLACE PART
CLEAN REPLACE PART
CLEAN REPLACE PART
CHECK VALVE
PARTS
HELD AT PSID
AND
❑ ❑
0 ❑
O ❑
LEAKED ❑
REPAIRS
❑ O
❑ U
0 0
❑ O
O ❑
0 ❑
CLEANED ❑
O O
O O
0 ❑
REPAIRED O
TEST AFTER
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LEAKED ❑
LEAKED O
OPENED AT PSID
AIR INLET PSID
PASSED O
#1 CHECK PSID
CHECK VALVE
FAILED ❑
PSID
PSID
PSID
AIR GAP INSPECTION: Requi minimum air gap separation provided? Yes 0 No O Detector Meter Reading
REMARKS: LINE PRESSUREaC'3 PSI
CONFINED SPACE?
TESTER SIGNATURE &&L"- CERT. NO. � 0 � DATE S -&72'0.
TESTER NAME PRINTED TESTER PHONE # (v2C% ClaO q'c
REPAIRED -BY;
FINAL TEST BY:
CERT. NO.
DATE
DATE
CALIBRATION DATE:/ice l GUAGE# bjq MODEL SERVICE RESTORED? YES NO O.
/ certifyrthat this report is accurate, and 1 have used WAC 246-290-490 approved test methods and test equipment.
"Drnnrictar%t A (nnfiriAntini"
V Aft
GUARDIAN SECURITY
Seattle ❑ Silverdale ❑ Bellingham
1743 First Avenue South 9435 Provost Rd. #204 1501 Kentucky Streeet
Seattle, WA 98134 Silverdale, WA 98383 Bellingham, WA 98229
206-622-6545 360-692-3738 360-647-0110
1-800-282-6998 1-800-366-1005
ASSEMBLY ID:
NAME OF PREMISE ` k'�"
`v 6A
W14 Backflow Prevention
Report (CTF-25)
Lie. # GUARDSS233KS
PASSED ANNUAL TEST: YES 0 NO 0
COMMERCIAL RESIDENTIAL 0
, i�3
SE CITY C ��� STATE` ZIP
SERVICE ADDRESS
CONTACT PERSON o `u�� PHONE} ` -P FAX
LOCATION OF ASSEMBLY4
DOWNSTREAM PROCESS ��� ��\0-�``� DCVA RPBA 0 PVBA ❑ OTHER:
NEW INSTALL ❑ EXISTING; REPLACMENT 0 OLD SER. # PROPER INSTALLATION? YESU NO ❑
.�
MAKE OF ASSEMBLY `�" O ___ MODEL '% r, SERIAL NO. 0\1Qi!�,t t�SIZE nd
INITIAL
DCVA.1 RPBA
DCVA / RPBA
RPBA
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CHECK VALVE NO. 1
CHECK VALVE NO.2
AIR INLET
OPENED AT PSID
LEAKED ❑
LEAKED ❑
#1 CHECK PSID
OPENED
AT PSID
PSID
PSID
,PASSED
FAILED ❑
AIR GAP OK?
DID NOT OPEN ❑
NEW
CLEAN REPLACE PART
CLEAN REPLACE PART
CLEAN REPLACE PART
CHECK VALVE
PARTS
HELD AT
AND
0 ❑
U ❑
0 i7
_PSID
LEAKED ❑
REPAIRS
❑ ❑
❑ (3
p ❑
CLEANED 0
O O
❑ ❑
O ❑
❑ 0
0 0
❑ ❑
REPAIRED 0
TEST AFTER
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LEAKED ❑
LEAKED O
OPENED AT PSID
AIR INLET — PSID
PASSED O
#1 CHECK PSID
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FAILED 0
PSID
PSID
PSID
AIR GAP INSPECTION: Required minimum air gap seperation provided? Yes ❑ No p Detector Meter Keaaing
REMARKS: }�`-' LINE PRESSURE _ PSI
CONFINED SPACE?
TESTER NAME PRINTED
REPAIRED BY:
CERT. NO. DATE :3
TESTER PHONE # :.�L 62- L
DATE
FINAL TEST BY: CERT. NO. DATE '
..r
CALIBRATION DATE: 31 F7! t GUAGE#��Q';C�.�MODEL _ SERVICE RESTORED? YESOR NO 0",
I certify -that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment.
"O.i..�►i.-.4nni P. (`nnfir4cr%finl"
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CITY OF EDMONDS
BUSINESS LICENSE APPLICATION— COMMERCIAL
FEE: $125.00
CITY CLERICS OFFICE, BUSINESS'LICENSE DIVISION
121 5' AVENUE NORTH, EDMONDS, WA 98020 PHONE: 425.775.2525
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OFFICE USE ONLY
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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.
BUSINESS NAME FO p,-r ^ (, E- ZL w 1�_c L L- -
BUSINESS ADDRESS L Z 3 ?,.a �- O ofg o z o
Street Suite No. Zip Code
MAILING ADDRESS 933, G V-eY S'6 V1e r; W &J (cL 1t;0 (cam D
Street or PO Box �c Suite No. City, State and Zip Code
BUSINESS PHONE NO. (Z 06 1_ / D 1 " 8 Qc5�1/lA STATE TAX ID NO. (UBI NO.)C�r� )�o
BUSINESS E-MAIL �Y �OSey�f® t. qI Ct 6 . C.OY113l1SINESS WE13SITE cowg)_F0E-TAAX A 4p11�[E(,LY,(iEYS. COG/1
PROPERTY OWNER N�k2R Y CT 0 SOr'l 00,54
EMERGENCY NOTIFICATION (For Premise Access in Emergency):
5�t! to _L k o ! '*
Last
NATURE OF BUSINESS
Phone Number
2d�'D`1�00 0--
Phone No.
Zoe .), 6 12 - I !Qt O
Phone Na.
(� 117I'�T E TQ
`7
NUMBER OF EMPLOYEES f SQUARE FOOTAGE OF BUSINESS SPACE �Z
TYPE OF BUSINESS - PLEASE CHECK;THE APPROPRIATE CATEGORY.
O CONSTRUCTION • O FINANCE, INSURANCE, REAL ESTATE O LANDSCAPE, HORTICULTURAL O MANUFACTURING O NON-PROFIT
O RETAIL O SECONDHAND DEALER O SERVICES O WHOLESALEOTHER STO R14 Gr E
AMUSEMENT DEVICES70NPREMISES? .11 YES ,XNO . IF YES, TOTAL NUMBER
LIQUOR SOLD ON PREMISES?: O YES )NO. GAMBLING? DYES )4NO . CIGARETTES SOLD ON PREMISES? OYES )4NO
FLAMMABLE OR HAZARDOUS MATERIALS USED OR STORED?: O YESXNO IF YES, PLEASE PROVIDE LIST OF MATERIALS AND QUANTITIES:
�a
Flml Name
Name
PROPOSED OPENING DAY -OF BUSINESS O 19 BUSINESS HOURS '�
DAYS OPEN 9 UNDAY 0 TADNDAY t3TUESDAY �EDNESDAY kr f URSDAY AR f-RIDAY lergATURDAY
PARKING SPACES ON SITE: TOTAL ACCESSIBLE FOR PERSONS WITH DISABILITIES Z--
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? ArIES O NO
PREVIOUS BUSINESS USE AT THIS ADDRESS Z� TV E /0-10U`
iry
NAME
Last First MI
ADDRESS
Street Apt. No., Unit No. City, State and Zip Code
HOME PHONE NO. (_DOL NO. (DRIVERS LICENSE NO.) OR OTHER 10 NO.
DATE OF BIRTH CITY AND STATE OF BIRTH COUNTRY OF BIRTH
PARTNERSHIP -PARTNER 1
NAME
Last First to
ADDRESS
Street APL No.. Unit No. City, State and Zip Code
HOME PHONE NO.( DOL NO. (DRIVERS LICENSE NO.) OR OTHER ID NO.
DATE OF BIRTH CITY AND STATE OF BIRTH COUNTRY OF BIRTH
PARTNERSHIP -PARTNER 2•
NAME
Last
-First MI
ADDRESS
Street Apt. No., Unit No. City, State and Zip Code
HOME PHONE NO,( ) DOL NO. (DRIVERS LICENSE NO.) OR OTHER 1D NO.
DATE OF BIRTH CITY AND STATE OF BIRTH COUNTRY OF BIRTH
NAME OF
CORP.
CORPORATE OFFICERS:
Last Name
i{oSa yy
S t4C<,G-wt 114 N.
c t , / CORPORATION
TA L-E � A n �/�/ I 1 q Vim— FEDERAL TAX ID NO47 ^ 44lf 1 �478
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Suite• Apl., Unfl No. City: State and Zlp Coda l Q O9& Z
First Name MI Title Date of Birth DOL No. (Drivers License No.) or Other'ID No.
MalY11Y g{� C�fo O ��NOSE�It P����
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LOCAL CONTACT 14OSr!" )F ��R`� � •tlRK.1Qcs q L ",72 6 QO? 6--wo M.F- s
Name f First Name r MI Tide Phono No. DOL No. (Drivers Lic. No.) or Other 10 No.
APPU
Name —Pri Signatuie Title Date
.CIT•Y USEONLY:
PLANNING•OEOT. &APPROVE ' ODISAPPROVE
DATE_
�: SIGNATURE'_'
ZONING CODE '
CONDITIONAL USE PERMIT
t:OAitINENTS
.
IBUILDING:DEPT. ' O'APPROVE
CI DISAPPROVE
DATE
SIGNATURE
OCCUPANT LOAD
BUILDING PERMIT
OCCUPANCY GROUP '
COMM
'FIRE DEFT. OAPPROVE
0 DISAPPROVE
DATE
" SIGNATURE ,
U.F,I.R..
'COMM
POLICE DEPT. O APPROVE
O DISAPPROVE
DATE
SIGNATURE
Comm
iw
W.
FIRE PREVENTION
`
' Servin Brier; Edrrronds, and
gMountlake
12425 Meridian Ai'e SSNOHOMISH
INSPECTION REPORT
CO.
(ma.
❑ S
Terrace
FIRE❑BRIER
Everett, WA 98208
BRIEREDMO
SThwTwwwFireDistrict].Phone
(425) 551-1200
Fax
❑ UNINCOMOUNTPO TERRACE
❑UNINCORPORATED
org
(425) 5 51-1272
FREQUENCY
STATION & SHIFT
LOCATION: 123 2nd Avenue S Suite 105 98020
2 Year
,13 17-C
BUSINESS NAME: Vacant
PHONE:
SCHEDULED Dec 2013
DATE DUE
MAILING
UFIR / 591
ADDRESS: 123 2nd Avenue S, Suite 105, Edmonds, WA
98020
BUSINESS OWNER:
HOME PHONE:
Email:
EMERGENCY-1:
HOME PHONE:
CURRENT
KEY ACCESS-2:
HOME PHONE:
CITY YES NO
// BUSINESS
EMAIL:
/ LICENSE
INITIAL INSPECTION DATE
PERSON CONTACTED:
NAME OF INSPECTOR:
/
FIRE SYSTEMS: FE
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
1
1
2
2
3
3
4
4
5 ---------.�—. ---- - ---- --- --
6
-
-- --
5
6
7
7
1 AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1st RE -INSPECTION
DATE DUE: _
-
2nd RE -INSPECTION
DATE DUE: m_...__.
EXTENSION
GRANTED TO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
INSPECTOR:
PERSON
CONTACTED:
I
INSPECTOR:
INSPECTOR:
DATE:
2
3
DATE,
DATE, •
VIOLATIONS
1 5
VIOLATIONS
1 5
PRE -CITATION
LETTER SENT
DATE:
CITATION ISSUED
NUMBER:
CODE
SECTION:
4
5
2
6
2
3
6
7
3
7
RETURN RECEIPT
RECEIVED
6
4
$
4
$
DATE:
DISPOSITION:
7
LETTER NEEDED ❑ YES ❑ NO
LETTER NEEDED ❑ YES ❑ NO
g
FIRE DEPARTMENT COPY
- CITY OF EDMONDS
121 5TH AVENUE N. • EDMONDS, WASHINGTON 98020 • (425) 771-0215
v FIRE DEPARTMENT
41st 1a90
LOCATION: 123 2nd Ave S
BUSINESS NAME: AOFEA Tour Consultants t
A- ..
MAILING PO BOX 849
FIRE PREVENTION
SAFETY SURVEY
105-
PHONE: 4256728644
ADDRESS: Edmonds 98020
BUSINESS OWNER: Davies,-H ijgh HOME PHONE:
EMERGENCY;-1: Olson, Kenneth HOME PHONE: 3602978157
KEY ACCESS-2: McLaughlin, Christine HOME PHONE: 3608302906
FR 'TEENCY
STATION & VIFT
SCHEDULED
101f 10
DATE DUE ►
UFIR ► 591
1 i202
1 1 1 INITIAL INSPECTI N DATE
PERSON CONTACTED: e��1"N Q 1 S
NAME OF INSPECTOR_ U 'Foe(6 d Cr JLY
FIRE FE`f
SYSTEMS_
m• ANNUAL
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
1
ENTER CODE ONLY ONCE ►
VIOLATION CODE
1
2
2
3
3
4
4
5
5
6
6
8
8
1st RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTED TO:
INAL RE -INSPECTION
DAT 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
7
4
'8
4
8
DATE:
DISPOSITION:
8
LETTER NEEDED [] YES NO
LETTER NEEDED ❑ YES NO
�, FIRE DEPARTMENT COPY