21216 80TH AVE W (3)ZI
4t,
SNOHOMISk,C0. Serving Brier_.Zdmonds, and 12425 Meridian Ave S
Mountlake Terrace! Everett, WA 98208
FIRE
Phone (425) 551-1200
DISTM Twww.FireDistrict1.o'r9 Fax (425) 551-1272
LOCATION:
21216 80 Avenue W 98026
BUSINESS NAME�'.tl-
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ADDRESS: '�1216 8bth Avenue W, Edmonds, WA 98026
BUSINESS OWNER .: Hoov&, S
EMERGENCY-1: Dootson, Michael
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NAME OF INSPECTO�:
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HOME PHONE:
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AXEDMONDS
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DATE DUE 0 Feb 2016
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INITIAL INSPECTION DATE
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HAZARDS FOUND AND'LOCATIONS COMMUNICATIONS.
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I AGREE TO,CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
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DATE 0 . UE:
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2nd RE -INSPECTION
DATE DUE:
EXTENSION
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LOCATION: 212 , 16 80 th Avenue W 98026 2015 20-A
C�acant 4257781404 SCHEDULEDFeb 2015
BUSINESS NAM PHONE: DATE DUE
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MAILING ' 21216 80th AVenue W,"Edimonds, WA 98026 LIFIR 1,
ADDRESS:
Hoover, S
BUSINESS OWNER: HOME PHONE:
Dootson, Michael
4257781404 'CURRENT
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HOME PHONE:
YES
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I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS
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2nd RE -INSPECTION
EXTENSION
RE -INSPECTION
VIOLATIONS
DATE DUE:
DATE DUE:
GRANTEDTO:
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PERSON
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CITATION ISSUED
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NUMBER:
4
2
6
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%
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DATE:
CODE
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RETURN RECEIPT
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RECEIVED
DISPOSITION:
4
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DATE:
7
LETTER NEEDED [:] YES El NO
LETTER NEEDED C] YES NO
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FIRE DEPARTMENT COPY
'SNOHOMISH CO.
''FIR
�'DISTR __'T
Serving Briei: Edmonds, and 12425 Meridian Ave S
I-mountlake Terrace Everett, WA 98208
Phone (425) 551-1200
www.FireDistrictl.org Fax (425) 551-1272
— _ —_ w
FIRE PREVENTION
INSPECTION REPORT
0 EDMONDS
El BRIER
0 MOUNTLAKE TERRACE
[I UNINCORPORATED
FREQUENCY
STATION & SHIFT-*'
LOCATION:
21216* 80 th Avenue W 98026.
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BUSINESS NAME:
Vacant
PHONE:
42577814Ga
SCHEDULED
0 Feb 2014
DATE DUE
MAILING
UFIR593 156
ADDRESS:
21216 80th Avenue W, Edmonds,
W.A 980'26
BUSINESS OWNER:
Hoover, S
HOME PHONE:
EMERGENCY-1:
Dootson, Midiael
HOME PHONE:
4,957781404
CURRENT
KEY ACCESS-2:
HOME PHONE:
CITY YES NO
BUSINESS
El
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EMAIL:
LICENSE
INITIAL INSPECTION DAT�
PERSON CONTACTED:
((A
NAME OF INSPECTOR:
FlP.E.,SYSTEMS:
FE
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HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
2
2
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3
3
4
4
5
5
6
6
7
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I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
lst RE -INSPECTION
2nd RE -INSPECTION
FINAL RE -INSPECTION
EXTENSION
VIOLATIONS
DATE DUE:
DATE DUE:
GRANTEDTO:
DATE DUE:
CITED:
PERSON
PERSON
PERSON
CONTACTED:
CONTACTED:
CONTACTED:
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INSPECTOR:
INSPECTOR:
INSPECTOR:
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DATE:
DATE:
DATE:
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VIOLATIONS
VIOLATIONS
PRE -CITATION
CITATION ISSUED
1 5
1 5
LETTER SENT
4
—NUMBER:
CODE
5
2
6
2
6
DATE:
SECTION:
RETURN RECEIPT
3
7
3
7
RECEIVED
6
DISPOSITION:
7
4
18
4
8
DATE:
LETTER NEEDED [:3 YES NO
LETTER NEEDED YES NO
8
k FIRE DEPARTMENT COPY
P _- --"A/ Flu
MAR 3 0 1999
WASHINGTON STATE PATROL
FIRE PROTECTION BUREAU
REQUEST FOR INSPECTION
UW
Facility to be Inspected: Region
PROVIDER NUMBER.
Name
No yes
Change of Name?
Address
if Yes, please indicate:
city ZIP Code 9ye 3,1()
Former Name
Administrator
New Nam RFCFIVEn
Alternate Contact
Change of Addreu? No yes
MAY 2 4 1999
Maintenance Director
If Yes, please indicate new address: EDMOND9 FIRE DE
Phone
Fax
Type of Inspection Requested:
Now Ra�ewa Rehispectlon Special
Facility Licensed As:
Nursing Home 0 Boarding Home Hospital
Other
ATF ARTF� CRTC
Childbirth Center Other state
irT-1 8 Beds #T-1 9 Beds Total Beds
Occupancy
Year Buiilt' 0)17 IA-7 710 So 0)'7
Fe
,�are
r
Construction
Local Fire Depai
# of Stories
Contacted: No
0 Yes
Basement/Ceilar
Auto Sprinkler System No.
0' Part 0 Full
Inspected On By
ction System
Auto Date' No
C3 Part /lq Full
Inspected On BY
I f
C3
.
V /
By
Manual Fire Alarm No
Yes
Inspected On
Commercial Range Hood 0
yes
Inspected On _BY
Generator No
yes
lnsipect�d. On By
Fire Drills Complete C3 No
Yes
Day Evening Night
Rainspection Required No
Part Date
Approved for Licensing
Approved for Title 18 Clmtf, 19 0
Date
Inspected By 66 0
Disapproved (see 3000-450-470)
—Approved as Re quested
Date Approving Authority
Request Disapproved
WASHINGTON STATE PATROL
FIRE PROTECTION BUREAU
Ul=.
FIRE AND LIFE SAFETY INSPECTION: STATEMENT OF DEFICIENCY & CORRECTIVE ACTION
FACILITY
NAME
i"�4a
ADDRESS
'211 /0
CIT
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zlp�W2-
INSPECTOR/� ,,7 ,t7 - X'�
AGENCY - STATE FIRE MARSHAL
WSP
DAT�
PR
ITEM
NO._
STATEMENT OF DEFICIENCY
CODE OR WAC
REFERENCE
CORRECTIVE ACTION REQUIRED
CORRECTION REQUIRED
BY (DATE)
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THE DEFICIENCIES DESCRIBED ABOVE HAVE BEEN EXPLAINED TO ME,
AND I AGREE TO MAKE CORRECTIO NS NOT LATER THAN THE DATES
INDICATED.
!-]
URE OF(ACILLTY_� ANA R
2) m Z�
IREINSPECTION DATE/
RIGHT OF APPEAL
PAGE__/ OF PAGES
A facility aggrieved by the corrective orders of the State Fire Marshal or authorized representative may appeal to the State Fire Marshal within five
days of the order. If the State Fire Marshal confirms the order, it shall remain in force.
3000-450-470 12196 DISTRIBUTION: e White - State Fire Marshal 9 Yellow - License Agency e Pink - Facility e Gold - Inspector