21810 76TH AVE W STE 202Ala'
Serving Brier, Eurri6nds, and
f0misli CO.
Mountlake Terrace
FIRE
DISTwww.FireDistrictl.orz
71
12425 Meridian Ave S
Everett, WA 98208
Phone (425) 551-1200
Fax (425) 551-1272
LOCATION: 21810 76 th Avenue W Suite 2OZ98026
BUSINESS NAME: PHONE:
MAILING
ADDRESS: 21810 76th Avenue W, Suite.=, Edmonds, WA 98026
FIRE PREVENTION
INSPECTION REPORT
EDMONDS
BRIER
MOUNTLAKE TERRACE
UNINCORPORATED
FREQUENCY I STATION & SHIFT
2016 20-D
SCHEDULED Nov 2016
DATE DUE 1'
LIFIR 0 593 156
BUSINESS OWNER:
HOME PHONE'
EMERGIIENCY-11:Saimad- Jamps
a/A
H 0 M E P H 0 N E: 5.9 12
�—CURRE-Nft`
KEY ACCESS-2:
HOME PHONE:
CITY
YES NO
EMAIL:
BUSINESS
LICENSE
F
y
PERSON CONTACTED:
INITIAL INSPECTION DATE
F '
NAME OF INSPECTOk
Lg t-
I (a
FIRE SYSTEMS: FE 1j_jp
Date Last Serviced:
Serving Brier, E4mqnds, and
Mountlake T�rrace
www.,,FireDistrictl.org,
12425 Meridian Ave S
Everett, WA 98208
Phone (425) 551-1200
Fax (425) 5i5l-12 72
0' FREQUENCY N & SHIFT
LOCATION:
SCHEDULED
PHONE:
BUSINESS NAME:i,
21810 76 th Avenue W Suite 200 98026 DA2� 11' 16-A
MAILING LIFIR If
Pagar�),Justin DDSMSD 4257753564 Feb 2016
ADDRESS:
N.
BUSINESS OWNER:, t HOAMPE:
21810 76th A, venue W, %ite 200, Edmonds, WA
HOME PHONE: 01
EMERGENCY 1.-
KEY ACCESS-241
HOME PHONE:,,
EMAIL:'
ell Pacial I, dustil 1 2162623624
PERSON CONTACTED: G.1iiA—, Al
NAME OF INSPECTOR:
jV4
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FIRE PREVENTION
INSPECTION REPORT
�IffEDMONDS
[3 BRIER
UMOLINTLAKE TERRACE
[3 UNINCORPORATED
593157
CURRENT .1.
CITY YES ,NO
BUSINESS
LICENSE
TIAL INSPECTION DATE
CPMM
PfwW,qqqfM1g) Locft I NS T /f, UNICATIONS
0ate Last Serviced7
_60'.
_A;4'7:T
2 JI
2
3
3
4
.5
6
6
7
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1st RE -INSPECTION
2nd RE -INSPECTION-
EXTENSION
FINAL RE -INSPECTION
VIOLATIONS
DATE DUE:
DATE DUE:
GRANTEDTO:
DATE DUE:
CITED:
PERSON
PERSON
PERSON
.ECNILA�TED
CONTACTED:
CONTACTED:
1
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
VIOLATIONS:%
PRE -CITATION
CITATION ISSUED
1
LETTER SENT
NUMBER:
4
2 6
2
DATE:
CODE
SECTION:
5
RETURN RECEIPT
3
7
3
7
RECEIVED
DISPOSITION:
4
8
DATE:
LETTER NEEDED [] YE S
_j
LETTER NEEDED 0 YES [:1 NO
8
SNOI
F
b
Serving Brier, Edmonds
Mountlake Terraceand
the Town of Woodway
www.FireDistrictl.org
LOCATION:
21810 76th Avenue
BUSINESS NAME:
James A. Salman, M.D.
MAILING
21810 76th Ave W 4202
ADDRESS:
Edmonds
BUSINESS OWNER:
Salman, James
EMERGENCY-1:
Gant, Thomas
KEY ACCESS-2:
PERSON CONTACTED:
NAME OF INSPECTOR:
'FIRE
SYSTEMS:
12425 Meridian Ave S
Everett, WA 98208
Phone (425) 551-1200
Fax (425) 551-1272
W 202
PHONE: 4257715912
98026
HOMEPHONE: 4257715912
HOMEPHONE: 2069890293
HOME PHONE:
FIRE PREVENTION
INSPECTION REPORT
0 EDMONDS
0 BRIER
E]WOODWAY
[:1 MOUNTLAKE TERRACE
0 UNINCORPORATED
FREQUENCY
STATION & SHIF'*'
731
16 D
I
SCHEDULED
DATEDUE � 11101,112
UFIR � 593
11156
AC-TiVE
CURRENT
CITY YES NO
BUSINESS
LICENSE
INITIAL INSPECTION DATE
FE -, I
A�NLJIZ
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
2 A 0/,jDf5L 'LOA) �;-i
I A)
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
lst RE -INSPECTION
DATE DUE:
I
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 �p
2
6
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RE EIVED
6
4
18
18
E��
DISPOSITION:
7
�_�RNEEDED [] YES El No
�LE ER NEEDED [] YES::O: NO
8
FIRE DEPARTMENT COPY