21810 76TH AVE W STE 101-7 to -Hi 13 097 Q d-rr- /a/ FIRE PREVENTION
2101 INSPECTION REPORT
Serving B onds
12425 Meridian Ave S -
- - - - �
SNOHOMISH CO.
Mountlake Terraceand
FIRE'
Everett, WA 98208
0 EDMONDS
0 BRIER
- 40 e Town of Woodway
DISTR T
Phone (425) 551-1200
E]WOODWAY
MOUNTLAKE TERRACE
www.FireDistrictl.org
Fax (425) 551-1272
0 UNINCORPORATED
FREQUENCY STATION & SHIFT
LOCATION: 21810 76th Avenue
W 101
731 1 16 D
BUSINESS NAME: NW Dental Center
PHONE: 4257743710
SCHEDULED 1111101,112
DATE DUE
MAILING 21810 76th Ave W #10 1
UFIR 11, 593 1156
ADDRESS: Edmonds
98026
BUSINESS OWNER: Nabaie, Pooya
HOMEPHONE: 2067133512
AC71VE
EMERGENCY-1: Nabaie, Reza
HOME PHONE:
CURRENT
KEY ACCESS-2:
HOMEPHONE:
CITY YES NO
BUSINESS
El El
LICENSE
PERSON CONTACTED: A1111
A 09 r:
INITIAL INSPECTION DATE
NAME OF INSPECTOR: LAJ L_ I �j A)
No b) /t)-')O A)
FIRE FA 5/11
FIE S fl-2
SYSTEMS:
ANNUAL
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
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2
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2
3
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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.
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 15
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
4
18
DATE:
DISPOSITION:
7
LETTER NEEDED C] YES No
LETTER NEEDED [] YES El NO
8
FIRE DEPARTMENT COPY
W, - �-Ms§ M.1T-1WrsG�GTM@ 01--re o =ei MM-10 el I §�=
05/16/2011 12:46 FAX 4253538934 Evergreen Security 0 003
FIRE PROTECTION BUREAU — FIRE AND LIFE SAFETY INSPECTIONS
PO Box 42600 Olympia. WA 98504-2600
(360)596-3000 FAX: (360)596-3934
FIRE ALARM SYSTEM INSPECTION REPORT
RETAIN COPY ON PREMISES
w
CITY OF EDMONDS
121 ST" AVENUE N. - EDMONDS, WASHINGTON 98020 - (425) 771-0215
FIRE DEPARTMENT
FIRE PREVENTION
SAFETY SURVEY
LOCATION: 21810 76th Avenue w 101
BUSINESS NAME: NW Dental Center PHONE: 4257743710
MAILING 21310 76th Ave W #10 1
ADDRESS: Edmonds 98026
BUSINESS OWNER: Nabaie, Pooya HOME -PHONE: 2067133512
EMERGENCY-1: Nabaie, Reza HOME PHONE: 4254020451
KEY ACCESS-2: HOME PHONE:
FREQUENCY
STATION&SHIFTJ
731
16 B
I
SCHEDULED
DATE DUE 111
11/01/10
LIFIR 0, 593
1'156
ACTIVE
INITIA ION DATE
PERSON CONTACTED: 1,1--sci �) rnLkL[L+L
NAME OF INSPECTOR:
FIRE FE 3 110
SYSTEMS:
HAZARDS FOUND
ANNUAL
�11
AND LOCATIONS / COMMUNICATIONS
ENTER CODE ONLY ONCE I�
VIOLATION CODE
-0t 0 A� ot3
2
2
3
3
04,
4
It
5
5
6
6
7
7
8
8
1st RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTED TO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
COPfIACTED:
PERSON
CONTACTED:
I
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
1 5
VIOLATIONS
1 5
PRE-CRATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2
6
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED
6
7
4
18
14
18
DATE:
DISPOSITION:
8
LETTER NEEDED [] YES NO
LETTER NEEDED 0 YES NO
FIRE DEPARTMENT COPY
j'01/2e/2010 11:42 FAX 4253538934
1
it Me, @MM4,101
Evergreen SecuritY
11004
Washington State Patrol
Fire Protection Bureau
General Administration Building
Post Office Box 42600
Olympia, WA 98504-2600
Name of Facility:
occupied As:
inspection Contract No.
File Number__---.
Fire Alarm System
Report of Inspection
401
Address: AA
Telephone4
County: Zip. X-0� . P5
Building Designation (if more than one building):
Title:
inspected BY:
Date Of Inspection, 4"
1, Type of Test: Monthly 1 11 Quarterly 13 Semi -Annual 0 Annuaxo'
2. Type of System: NoncodedA�Comrnon Coded 0 Selective Coded [I Dual Coded 13
3, Local Fire Department:
4. Fire Department Official Contacted: — 0- pt—' ---------------
5 Test Received at Fire Department: 0 Yes J�No
A.M. P..M.
6. Master Box Reset
7. Comments, explanabon of uns3tisf3ctory rosults, action taken, etc ... : —
1111111"ORM= 41111ME1
0
01/2PO/2010 11:42 FAX 4253538934 Evergreen Securltv
0005
Type of Equipment
of Units LeM
Test Date
satisfactory Check
-Yes No N/A
Type and Manufacturer-
8. Control Panel
-Number
9. Manuel Station
10, Heat Detectors
It. Smoke Detectors
12. Audible Alarms
13. Visual Alarms
14. Code Transmifters
15. Auto Door Releases
16. Trouble Indicators
6:7
17. Master AlAnn
_BOX
18. Batteries
19. Charger
20. Generato
21. Ventilation Control
22. Fire Department
Intemonnection
23. Central Station
Interconnection
24. Exterior Sprinkler
Electric Alarm Bell
25. Sprinkler Water
Flow Switch
26. Sprinkler Gate
Va ve amper Switch
7
27, Enunciators
28. Automatic Time Delay of General Alarm _Minutes None Installepf
29. Test of alarm system on emergency power satisfactory? Ye2� No E3
30. This is to certify that this fire alarm system ha's beeh properly inspected for reliability
covering the times listed In this report, and is consistent with NFPA Fire Alarm Maintenance
Standards.
A. Signature of Owner or Representativ
B. Signature of Fire Alarm Firm Representative
'EveEgreen SecuriW 5 �ms. Inc. z
C. Name of Firm ys 4
D. Mailing Address 8115 Broadway Suite 101, Everett, WA.98203
E. Electrical Contractors Ucense# EVERGS1112L2-
F. Specialty Electricians Ucense#
t100--
1890 9 c�
N 0 T I C
TO PERMITTEE AND/OR OWNER
F-1 PARTIAL APPROVAL
�F-I V OLATION
�cvo'RRECTIONs REQUIRED
Permit Number Owner A/'�"
C7- _gizjL�
Job Address �Z, EA 0 7 to 14,V V�/
No PERMIT -STOP WORK -REMOVE CONSTRUCTION OR OBTAIN PERMIT AND MAKE WORK COMPLY
F-1 WITH ALL APPLICABLE CITY CODES.
F-1 CONSTRUCTION Is NOT IN ACCORDANCE WITH APPROVED PLANS AND PERMIT - STOP WORK.
MAKE WORK COMPLY WITH APPROVED PLANS AND PERMIT OR REMOVE.
F-1 STOP WORK - UNTIL AUTHORIZEI) To CONTINUE By CITY INSPECTOR.
CORRECTIONS LISTED BELOW MUST BE MADE: BEFORE WORK CAN BE APPROVED AND/OR THE
NEXT PHASE IS STARTED; To AVOID POSTING OF A STOP WORK ORDER, ORDER To
CORRECT, OR ABATEMENT PROCESS.
F—A JOB CARD MUST BE POSTED ON SITE AND BE VISIBLE FROM STREET.
D
71
F-1
F-1
APPROVED PLANS MUST BE AVAILABLE To INSPECTOR ON SITE.
WORK DESCRIBED BELOW HAS BEEN INSPECTED AND Is APPROVED.
CONTACT INSPECTOR AND ARRANGE FOR APPOINTMENT.
RECALL FOR INSPECTION.
I z:_' F_t��Z_
A-t,Y6 /,A rk.-r'
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-riL- 16 -47f
15,j e&4,.o VC- L
THE ACTIONS OR CORRECTIONS INDICATED ABOVE ARE REQUIRED WITHIN
DAYS OR PENALTIES MAY BE APPLIED. FOR INSPECTIONS CALL 771-0220.
F-A Department
Building Division LiPlanni g Department L] Engineering Department arFire
,-,A 11'��CWTY OF EDMONDS
,f , <,y( q In ector Date