21600 HWY 99 STE 110SNOHOMISH CO.
FIRE-
STRIfIt":1T
Serving Bir'h n ds
Mountlake Terraceand
the Town of Woodway
www.FireDistrictl.org
12425 Meridian Ave S
Everett, WA 98208
Phone (425) 551-1200*
Fax (425) 551-1272
FIRE PREVENTION.
NSPECTION REPORT
OEDMONDS
0 BRIER
E]WOODWAY
0 MOUNTLAKE TERRACE
0 UNINCORPORATED
r- FREQUENCY
STATION & SHIFT'*)
LOCATION:
21600 Highway 99
110
1j] Ila u
BUSINESS NAME:
NW Dermatology
PHONE: 4257787546
SCHEDULED
DATE DUE 11' 01/01/13
MAILING
21600 Highway 99 #110
UFIR 11, 59-1
ADDRESS:
Edmonds
98026
111517
_j
BUSINESS OWNER:
Headley, John
HOMEPHONE: 4253380248
AC-nVE
EMERGENCY-1:
HOME PHONE:
CURRENT
KEY ACCESS-2:
HOME PHONE:
CITY YES NO
BUS NES
LICE NSE
PERSON CONTACTED: c)1- L
INITIAL INSPECTION DATE
NAME OF INSPECTOR:
o2-
-7 - / 3
FIRE
FE a/_LZ-
SYSTEMS:
ANNUAL
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
2
2
3
3
4
4
5
5
6
6
7
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1st 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:
D E:
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
4
8
4
8
DATE:
DISPOSITION:
7
LETTER NEEDED YES No
FETTER NEEDED YES NO
F
8
FIRE DEPARTMENT COPY
t �
CITY OF EDMONDS
121 5TH AVENUE N. - EDMONDS, WASHINGTON 98020 - (425) 771-0215
FIRE DEPARTMENT
LOCATION: 21600 Highway 99
BUSINESS NAME: NW Dermatology
MAILING 21600 Highway 99 #110
FIRE PREVENTION
SAFETY SURVEY
PHONE: 4257787546
ADDRESS: Edmonds 98026
BUSINESS OWNER: Headley, John HOMEPHONE: 4253380248
EMERGENCY-1: HOME PHONE:
KEY ACCESS-2: HOME PHONE:
FREQUENCY
ION& SHIFT
STAT-1
731
6 6
1
SCHEDULED
01/011,11
DATE DUE 1�
LIFIR P- 593
1157
ACTIVE
INITIAL INSPECTION DATE
PERSON CONTACTED: AAJ 'C� F,
NAME OF INSPECTOR: DOWL 1/u 1-0- 2,01 1
FIRE FE Z-/ 116
SYSTEMS:
ANNUAL
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS ENTER CODE ONLY ONCE I�
0 — TIV 7 5 6AJ
VIOLATION CODE
2
2
3 " /k) A) A) CIP M A) A..0 -A P f-- a-
fL o
4
4 AA L) 0 U)
3 FZ-J 4
4
5
.......... .. . . . . .. ... .... ... ... .. .. .. ...
6
7
8
6
7
8
1st RE -INSPECTION
DATE D JE:
2nd RE -INSPECTION
DATE DUE:
PERSON
CONTACTED:
INSPECTOR
DATE:
VIOLATIONS
1 15
2 16
3
4
_�iTER NEEDED r_! Y
rL ES NO
EXTENSION FINAL RE -INSPECTION
GRANTED TO: DATE DUE:
PERSON
CONTACTED:
VIOLATIONS
CITED:
PERSON
CONTACTED:
2
DATE: (L
INSPECTOR:
DATE:
PRE -CITATION CITATION ISSUED
LETTER SENT NUMBER
CODE
DATE* SECTION:
RECEIVED
DATE.
3
-4
5
6
VIO ATIONS
2_6\
2
4
5
6
7
18
8
\,,UETTER NEEDED E] YES 7 No
FIRE DEPARTMENT COPY
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