21701 76TH AVE W STE 1044]
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FIRE PREVENTION
Se.
rving. Brier, Edmonds,, and 12425 Meridian Ave S INSPECTION REPORT
Mountlake Terrace Everett, WA 98208 0 EDMONDS
0 BRIER
Phone, (425) 551-1200 'E3 MOUNTLAKE TERRACE
[3 UNINCORPORATED'
www.FireDistrictl.org Fax (425) 551-1272
LOCATION: 21701 76 th * Avenue W Suite 104 98026
BUSINESS NAME: Edmonds Pharmacy PHONE: 4253462148
MAILING
ADDRESS: 21701 76th Avenue W, Suite 104, Edmonds, WA 98026
BUSINESS OWNER: HOME PHONE:
EMERGENCY-1: Arumilli, Saikrishna HOME PHONE: 4254936835
KEY ACCESS-2: HOME PHONE:
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EMAIL:
PERSON CONTACTED:
NAME OF INSPECTOR: 1,3 e_s5'
FIRE SYSTEMS: 'F If 7—Ll—r
e' FREQUENCY STATION & SHIFT
2015 20-C
SCHEDULED
DATE DUE Ii, Oct 2015
LIFIR 0 509 157
CURRENT
CITY YEP NO
BUSINESS
LICENSE
INITIAL INSPECTIIN DATE
Date Last Serviceds.
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
2 . . .........
2
3
3
4
4
_5
6
6
7
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
lst RE -INSPECTION
2nd RE -INSPECTION
EXTENSION
FINAL RE -INSPECTION
VIOLATIONS
DATE DUE. q-
DATE DUE:
GRANTEDTO:
DATE DUE:
CITED:
PERSON
PERSON
CONTACTED:
CONTACTED:
PERSON
CONTACTED:
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
E:
DATE:
3
VIOLATIONS
V10 IONS-
PRE -CITATION
CITATION ISSUED
5
1
LETTER SENT
NUMBER:
4
6
2
DATE:
CODE
SECT ON:
5
-6
RETURN RECEIPT
3
7
RECEIVED
DISPOSITION:
4
-8
4
8
DATE:
7
�'LETTER NEEDED YES NO
LETTER NEEDED [] YES 0 NO
SNOHOMISH CC
TIRE
ST
Serving Brier Edinonds
Mountlake Terraceand
the Town of Woodway
www.FireDistrictl.org
LOCATION: 21701 76th Avenue
BUSINESS NAME: Edmonds Phairmacy
MAILING 21701 76th Ave W #104
ADDRESS: Edmonds
BUSINESS OWNER: Arumilli, Sailcrishna
f EMERGENCY-1: Arumilla, Jay
KEY ACCESS-2:
PERSON CONTACTED:
NAME OF INSPECTOR: V'J AA a Ee-j c� 0 C
FIRE
SYSTEMS:
12425 Meridian Ave S
Everett, WA 98208
Phone (425) 551-1200
Fax (425) 551-1272
W 104 1125- 54.3-639,
PHONE: 426&462+*fl
98026
HOME PHONE: 4254936835
HOME PHONE: 4254936835
HOME PHONE:
FIRE PREVENTION
INSPECTION REPORT
0 EDMONDS
0 BRIER
OWOODWAY
0 MOUNTLAKE TERRACE
0 UNINCORPORATED
FREQUENCY STATION 1, SHIFT
730 16 C
SCHEDULED
DATE DUE 1' 10/01/11
UFIR 11, 593 1(157
ACTIVE
CURRENT
CITY
YES ' NO
BUSINESS
El
El
LICENSE
INITIAL INSPECTION DATE
FEI�
W
A14NUZ
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
1 f\10.4,je �o)
2
2
3
3
4
4
5 7z-
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.
1
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
—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:
LETTER NEEDED' El YES El NO
tETTER NEEDED [-] YES NO
8
FIRE DEPARTMENT COPY
COTY OF EDMONDS
BUSONESS LOCENSE APPLOCATOON- COMMERCOAL
FEE: $125.00
5C TY CLERK'S OFFICE, BUSINESS LICENSE DIVISION
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Inc. IS9 1215 AVENUE NORTH, EDMONDS, WA 98020 PHONE: 425.775.2525
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UTIL BILL
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INSTRUCTIONS: Please complete the application in full and attach the required floor plan. Middle Initial or name required of all
parties concerned. If no middle name, please Indicate by writing NMN. Sign and return application with fee. Please advise of
any change In status. New license required If business changes location or ownership. Notification to City of Edmonds required
if business closes.
BUSINESS NAME E—,Q A/VQ f43) S, kA hGAL713 �=�
'Plv)j 9 R C:'
BUSINESS ADDRESS Q 110 b!4
9treet Suitd No. Zip Code
MAILING ADDRESS '7�f W f f,) Lzat,_% W 9
Street or PO Box Suite No. City, State and Zip Code
BUSINESS PHONE NO. WA STATE TAX ID'NO. (UBI NO.) 9
BUSINESS E-MAIL nCt G.JV(ftUSINESSWEBSITE I-AA\,0W-
PROPERTYOWNER_
(Zia
Name Phone -Number
EMERGENCY NOTIFICATION (For Premise Access in Emergency):
Last Name
Name
MI Phone No.
Last Niffi-e Firit Nime Mi
NATURE OF BUSINESS f^ tv�
0 e w6vl)
NUMBER OF EMPLOYEES SQUARE FOOTAGE OF BUSINESS SPACE
t
TYPE OF BUSINESS - PLEASE CHECK THE APPROPRIATE CATEGORY:
0 CONSTRUCTION 0 FINANCE, INSURANCE, REAL ESTATE 0 LANDSCAPE, HORTICULTURAL 0 MANUFACTURING 0 NON-PROFIT
4#�_04 AIL 0 SECONDHAND DEALER .019thVICES OWHOLESALE 0 OTHER
AMUSEMENT DEVICES ON PREMISES? 0 YES ,W40 IF YES, TOTAL NUMBER
Ll QUOR SOLD ON PREMISES?: C3 YES GAMBLING? 13 YES
246 '7NO
CIGARETTES SOLD -ON PREMISES? 0 YES /No
FLAMMABLE OR HAZARDOUS MATERIALS USED OR STORED?: 0 YES1010 IF YES, PLEASE PROVIDE LIST OF MATERIALS AND QUANTITIES:
PM
PROPOSED OPENING DAY OF BUSINESS BUSINESS HOURS
DAYS OPEN 0 SUNDAY 1316'ONDAY 9-T6ESDAY 2-W—EDNESDAY 0-rH—URSDAY OT VZDAY - -�f�TURDAY
a
PARKING SPACES ON SITE: TOTAL a_t) ACCESSIBLE FOR PERSONS WITH DISABILITIES
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? 91-E S 0 NO
PREVIOUS BUSINESS USE AT THIS ADDRESS 1) 11V A� & rN& 111s�
SOLE PROPRIETORSHIP
Last First M1
ADDRESS
Street Apt. No., Unit No. City, -State -and Zip Code
HOME PHONE NO. (Jf h2?, =68 jCD-0L NO. (DRIVERS LICENSE NO.) OR OTHER ID NO. 2-4
DATE OF BIRTH 6$�CITY AND STATE OF BIRTH COUNTRY OF BIRTH
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PARTNERSHIP - PARTNER 1
NAME_
L - ast
First
MI
ADDRESS
Street
Apt. No., Unit No.
City, State and Zip Code
HOMEPHONENO.(
DOL NO. (DRIVERS LICENSE NO.) OR OTHER ID NO.
DATE OF BIRTH
CITY AND STATE OF BIRTH
COUNTRY OF BIRTH
PARTNERSHIP - PARTNER 2
NAME
Last
First
MI
ADDRESS
Street
Apt. No., Unit No.
City, State and Zip Code
HOME PHONE NO.(
DOL NO. (DRIVERS LICENSE NO.) OR OTHER ID NO.
DATE OF BIRTH
—CITY AND STATE OF BIRTH-
COUNTRY OF BIRTH
NAME OF CORPORATION FEDERAL TAX ID NO.
CORP.ADDRESS PHONE NO.(
Street Suite, Apt., Unit No. City, State and Zip Code
CORPORATE OFFICERS:
Last Name First Name MI Title Date of Birth DOL No. (Drivers License No.) or Other ID No.
ILOCAL CONTACT
Last Name
Name
AP P LI CAN T-C— &A )g JQ � & tj & jt�gk 71
Nami-'Printi-d - —
MI Title Phone No. DOL No. (Drivers Lic. No.) or Other ID No.
PLANNING DEPT. 0 APPROVE 0 DISAPPROVE DATE SIGNA
ZONING CODE CONDITIONAL USE PERMIT_
Al
Title URIP
BUILDING DEPT. 0 APPROVE 0 DISAPPROVE DATE SIGNATURE
OCCUPANTLOAD BUILDING PERMIT OCCUPANCY GROUP
COMMENTS
FIRE DEPT. 0 APPROVE 0 DISAPPROVE DATE SIGNATURE
U.F.I.R.
COMMENTS
POLICE DEPT. 0 APPROVE 0 DISAPPROVE DATE SIGNATURE
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