210 5TH AVE S STE 103103-
7;
FIRE PREVENTION —
A Serving Brier, Edmonds, and' 12425 Meridian Ave S INSPECTION REPORT
FIRESNOHOMISH CO -Mountlake Terrace Everett, WA'98208 OEDMONDS
0 BRIER
Phone (425) 551-1200 [3 M6UNTLAKE TERRACE
DISTR' T www''.FireDistrictl.org Fax (425) 551-1272 E3 UNINCORPORATED
LOCAT'ION: % FREQUENCY STATION 11 SHIFT
.210 5 th Avenue S Suite 1.03 98020 201- 17-C
BUSINESS NAME: PHONE: SCHEDULED
State Farm Ins./Dan Skeels 4256403091 DATE DUE 0 Apr 2016
MAILING FIR 0
591 202
ADDRESS: �u
210 5th Avenue S, Suite 103, Edmonds, WA 98020
,BLISINESS OWNER: HOME PHONE:
Skeels, Dan
EMERGENCY-1: HOME PHONE: eCURRENT
KEY ACCESS-2: Skeels, Dan HOME PHONE. 4256731888 CITY YES NO
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LICENSE
PERSON CONTACTED: INITIAL INSPECTION DATE
NAME OF INSPECTOR:
FIRE SYSTEMS: F E 'L/_jj
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COMMUNICATIONS-
2
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4
4
5
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I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
I st RE -INSPECTION
DATE DUE:
2nd RE -INS PECTION
DATE DUE:
EXTENSION
GRANTEDTO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
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INSPECTOR:
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VIOLATIONS
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LETTER SENT
CITATION ISSUED
NUMBER:
4
2
6
2
6
DATE:
CODE
SECTION:
5
3
4
7
7
RETURN RECEIPT
RECEIVED
6
18
4
8
DATE:
DISPOSITION:
7
LETTERNEEDED [] YES NO
LETTER NEEDED F] YES NO
8
CITY OF EDMONDS
121 STH AVENUE N. - EDMONDS, WASHINGTON 98020 - (425) T71-0215
FIRE DEPARTMENT
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LOCATION: 210 5th Ave S
BUSINESS NAME: State Farm InsJDan Skeels
MAILING 210 5th Ave N #103
ADDRESS: Edmonds
BUSINESS OWNER: Skeels, Dan
EMERGENCY-1:
KEY ACCESS-2:
FIRE PREVENTION
SAFETY SURVEY
103
PHONE: 4256403091
98020
HOMEPHONE: 4256731888
HOME PHONE:
HOME PHONE:
FREQUENCY
swriON & SHIFT
731
17 6
SCHEDULED
DATE DUE 11-
04/01/11
UFIR 0- 591 4202
INITIAL INSPECTION DATE
PERSON CONTACTED:
NAME OF INSPECTOR:
FIRE FE 11,0
SYSTEMS:
ANNUAL
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/ COMMUNicAnONS
ENTER CODE ONLY ONCE 0,
VIOLATION CODE
2
2
3
3
4
4
5
5
6
6
7
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8
8
11st 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
%,10LATIONS
1 5
VIOLATIONS
5
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2
6
_1
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED _ _
6
7
4
18
4
16
DATE:-
DISPOSITION:
8
�,UETTERNEEDED F] YES E] NO
LETTER NEEDED [_-] YES NO
FIRE DEPARTMENT COPY