21701 76TH AVE W STE 202 (2)'6NOliOMIS]
FIR
A17PI 7&4A. e-
'FIRE PREVENTION'
Serving'Brier, Edmonds I , bnd 12425 Meridian Ave S WsPECTION REPORT
Mountlake Terrace Everett, WA 98208, OEDMONDS
0 BRIER
Phone (425)'551-1200 [3 MOUNTLAKE TERRACE
[I UNINCORPORATED
www.FireDistrictl.org Fax (425) 551-1272
LOCATION: 21701 76 th Avenue W Suite 202 98026
BUSINESS NAME: Edmonds Oral Surgery'
PHONE:
FREQUENCY STATION & SHIFT
2015 1 20-C
SCHEDULED.
DATE DUE iOCt2015
-MAILING
R 11, 593 157
ADDRESS:
21701 76th Avenue W,
Suite 202, Edmonds,
WA 98026
BUSINESS OWNER:
Heldrid * e, Joh . n n- j,-,
9
HOME PHONE:
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EMERGENCY-1 :
Heldrige, John L.
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HOME PHONE:
2069726432* CURRENT
KEY ACCESS-2:,
HOME PHONE:
CITY YES NO
BUSINESS
EMAIL:
In
LICENSE El
PERSON CONTACTED:
INITIAL INSPECTION DATE
NAME OF INSPECTOR:
/?/2. ( kr
FIRE SYSTEMS: FE 7
'Date Last Serviced:
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
2
2.
3
3
4
4'
5 ---------
6
5
6
7
7
I AGREE TO CO RRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
I st RE -INSPECTION
_qATEDUE
-PERSON
CONTACTED:
!�tPECTOR:
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTED TO:
FINAL RE -INSPECTION
DATE DUE,
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON'
CONTACTED:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
5
VIOLATIONS,-`
5
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2
6
2
6
DATE:
CODE;
SECTION:
5
RETURN RECEIPT
RECEIVED
4
.4
18
DATE.,
DISPOSITION:
7
\,,LETTERNEEDIED YES NO
LETTERNEEDED [] YES NO_
8
. APPLICATION FOR PERMIT
FOR MATERIALS OR PROCESSES
January 3, 2012
Please verify and correct the following information:
Name of Company (DBA):
Edmonds Oral Surgery
Edmonds Location
21701 76th Avenue W #202
In conformity with the
terms of the International
'Ffr_eC6_d_eappIicati6n_ is --
hereby made to store, use
Compressed gases -oxidizers
or maintain the following
activity, storage or pro-
cesses:
Mailing Address:
21701 76th Ave. W, Ste 202
Edmonds, WA 98026
EFD UFIR #:
(for office use)
5932021 57
Your Signature
Your Name (print)
,fik,4-Al , �
Your Title
LID,
Please make corrections, attach $40 payable to the City of Edmonds and mail to:
Fire Marshal
Department of Fire Prevention
121-5 th Avenue North
Edmonds, WA 98020
FOR OFFICE USE ONLY
Rec'd
Check# 5004
SNOHOMISH CO. Serving Brier, Edinonds 12425 Meridian Ave S
Mountlake Terrace, and Everett, WA 98208
FIRE
r the Town of Woodway Phone (425) 551-1200
STR - T www.FireDistrictl.org Fax (425) 551-1272
LOCATION: 21701 76th Avenue W 202
BUSINESS NAME: Edmonds Oral Surgery PHONE: 4257441724
MAILING 21701 76th Ave W #202
ADDRESS: Edmonds 98026
BUSINESS OWNER: Heldridge, John HOME PHONE: 42-57-7465606
EMERGENCY-1: Heldridge, John HOME PHONE: 2069726432
KEY ACCESS-2: Sato, Alan HOME PHONE: 42!tf781527
PERSON CONTACTED:
NAME OF INSPECTOR:
FIRE V
SYSTEMS:
FIRE PREVENTION
INSPECTION REPORT
0 EDMONDS
0 BRIER
EIWOODWAY
[I MOUNTLAKE TERRACE
0 UNINCORPORATED
e' FREQUENCY I STATION 1, SHIF'*'
730 16 C
SCHEDULED 10/()1/11
DATE DUE II'
UFIR � 593 11157
A(-M.VE
00 CURRENT
CITY YES NO
BUSINESS
LICENSE 1:1 El
INITIAL INSPECTION DATE
FE I
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:
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
18
14 18
DATE:
DISPOSITION:
7
LETTERNEEDED [] YES NO
I LETTERNEEDED [] YES NO
8
FIRE DEPARTMENT COPY