21600 HWY 99 STE 210210
FIRE PREVENTION
CITY OF EDIVIONUS SAFETY SURVEY
121 5� AVENUE N. - EDMONDS, WASHINGTON 98020 - (425) 771-0215
FIRE DEPARTMENT
41-S C3 z FREQUENCY STATION & SHIFT-"
LOCATION: 21600 Highway 99 2101A 731 16 6
SCHEDULED
BUSINESS NAME: A�IC_tlt401d e9l PHONE. 4266 01/01/11�
;I rl.7
DATE DUE
MAILING 21600 Highway 99 #210 LIFIR P� 593 1157
ADDRESS: Edmonds 98026
W 1> .�4.1, r-17 71- 61910 1
HOM
BUSINESS OWNER: N ; r,�ZpC_Z i!j bO A,(I'N E PHONE: 42&M-2&2l ACTIVE
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EMERGENCY-1: 11 1!'411�'�5YHOME PHONE:
KEY ACCESS-2: HOME PHONE:
PERSON CONTACTED: INITIAL INSPECTION DATE
NAME OF INSPECTOR: — I I
FIRE F E L4� OY
SYSTEMS: ANNUAL
HAZARDS FOUND AND LOCATIONS / COMMUNICAT]IONS
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ENTER CODE ONLY ONCE 0-
VIOLATION CODE
2
c,<,b
2
3
3
4
4
5
5
6
6
7
7
8
8
lst 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
OLAnONS
5
VIOLATIONS
1 5
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
6
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED
6
4
18
4
18
DATE:
DISPOSITION:
2
8
1� LETTER NEEDED ID YES NO
LETTER NEEDED F] YES F] NO
FIRE DEPARTMENT COPY
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.
Serving Brier, Edmonds
12425 Meridian Ave S
SNOHOMISH CO.
FIRE
Mountlake Terraceand
Everett, WA 98208
SI T
the Town of Woodway
T
Phone (425) 551-1200
www.FireDistrictl.org
Fax (425) 551-1272
LOCATION:
216300 Highway 99
210
BUSINESS NAME:
Michael G. Deming, MD
PHONE: 4257742426
MAILING
21600 Highway 99 #210
ADDRESS:
Edmonds
98026
BUSINESS OWNER:
Deming, Michael MD
HOME PHONE: 4257716010
EMERGENCY-1:
Carey, Cheryl A
HOME PHONE: 4257745894
KEY ACCESS-2:
HOME PHONE:
PERSON CONTACTED:
NAME OF INSPECTOR:
FIRE
SYSTEMS:
FIRE PREVENTION
INSPECTION REPORT
0 EDMONDS
OWOODWAY
0 MOUNTLAKE TERRACE
0 UNINCORPORATED
FREQUENCY I STATION & SHIFT`�
731 16 D
SCHEDULED
DATEDUE � 01/01/131
UFIR � 593 1157
ACTIVE
CURRENT
CITY
YES NO
BUSINESS
LICENSE
INITIAL INSPECTION DATE
FE
ANNUAL
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
1 1
2
2
3
3
4
4
5,
5
r6
6
7
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1 St R� INSPECTION
— DI
"DUE:
I., . . . ..... ... ..... .... ...
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
VIOLATIONS
1 5
VIOLATIONS
1 5
PRE -CITATION
LEWER SENT
CITATION ISSUED
NUMBER:
4
.2
6
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED
6
4
8
4
18
DATE:
DISPOSITION:
LETTER NEEDED [] YES N 0
LETTER NEEDED [] YES NO
8
FIRE DEPARTMENT COPY