21600 HWY 99 STE 130 (2)M
I ��
SNOHOMISH CO.
FIREPREVENTION
Z/ INSPECTION REPORT
Serving Br,� )nds 12425 Meridian Ave S 0 EDMONDS
Mountlake Terraceand Everett, WA 98208 0 BRIER
the Town of Woodway Phone (425) 551-1200 OWOODWAY
0 MOUNTLAKE TERRACE
www.FireDistrictl.org Fax (425) 551-1272 0 UNINCORPORATED
e FREQUENCY STATION & SHIFT"�
LOCATION: 21600 Highway 99 130 731 16 D
SCHEDULED
BUSINESSNAME: KrugerClinic ilhonaedics PHONE: 4257742636 0 01,1011,13
MAILING
ADDRESS:
BUSINESS OWNER: Degan, Thomas
EMERGENCY-1:
KEY ACCESS-2:
PERSON CONTACTED:
NAME OF INSPECTOR:
FIRE
SYSTEMS:
HOMEPHONE: 4257420146
HOME PHONE:
HOME PHONE:
LIFIR � 593 1157
ACTIVE
CURRENT
CITY YES NO
BUSINESS
LICENSE
INITIAL INSPECTION DATE
e2 — —7 - V:6
FE f
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
2nd RE-INSPECTI ON
FINAL RE -INSPECTION
EXTENSION
VIOLATIONS
DATE DUE:
DATE DUE:
GRANTED TO:
DATE DUE:
CITED:
PERSON
PERSON
PERSON
CONTACTED:
CONTACTED:
CONTACTED:
1
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATI6qS-
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
6
DISPOSITION:
7
14
18
4
8
DATE,_
�LET`TER NEEDED F] YES NO
rLETTER NEEDED E] YES [:1 NO
8
FIRE DEPARTMENT COPY
CITY OF EDMONDS
121 5TH AVENUE N. - EDMONDS, WASHINGTON 98020 (425) 771-0215
FIRE DEPARTMENT
LOCATION: 21600 Highway 99
BUSINESS NAME: Kruger Clinic Orthopedics
MAILING
ADDRESS:
BUSINESS OWNER: Degan, Thomas
EMERGENCY-1:
KEY ACCESS-2:
FIRE PREVENTION
SAFETY SURVEY
130
PHONE: 4257742636
HOMEPHONE: 4257420146
HOME PHONE:
HOME PHONE:
FREQUENCY
STATION & SHIFT
731
16 6
I
SCHEDULED
1
DATE DUE 11
J-01/1
UFIR 11- 593
1157
ACTIVE
PERSON CONTACTED: (—A LA v" tA LO r S INITIAL INSPECTION DATE
NAME OF INSPECTOR: -1 � 11
FIRE FE Tl�'
SYSTEMS:
ANNUAL
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
ENTER CODE ONLY ONCE 0
VIOLATION CODE
2
3
4
2
3
4
5
6
5
6
7
8
7
8
1st RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
PERSON
CONTACTED-
INSPECTOR:
DATE:
VIOLATIONS
1 5
2 16
3 7
4
LETTER NEEDED L YES NO
EXTENSION FINAL RE -INSPECTION
GRANTED TO:
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED -
INSPECTOR:
DATE:
PRE -CITATION CITATION ISSUED
LETTER SENT NUMBER:
CODE
DATE: SECTION:
2
INSPECTOR:
DATE: fd
VI )LATIONS
dif
1 15
2 16
3
4
5
3
7
RETURN RECEIPT
RECEIVED
DISPOSITION:
DATE:
4-
8
7
8
k, LETTER NEEDED �] YES E] NO
FIRE DEPARTMENT COPY