21911 76TH AVE W STE 101J- /Ou
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FIRE PREVENTION
INSPECT ION REPORT
Serving Brier, rurtivists., and 12425 Meridian Ave S'
Mountlake Terrace Everett, WA 98208 0 EDMONDS
0 BRIER
Phone (425) 551-1200 0 MOUNTLAKE TERRACE
0 UNINCORPORATED
www.FireDistrict].org Fax (425) 551-1272
LOCATION: 21911 76 th Avenue W Suite 101 98026
Eye Clinic of, Edmonds
BUSINESS NAME:
PHONE:
MAILING '-
ADDRESS: 21911 76th Avenue W, Suite 101, Edmonds, WA 98026
FREQUENCY STATION & SHIFT
2017 1 16-B
SCHEDULED Feb 2017
DATE DUE �
593157
LIFIR
BUSINESS OWNER:
HOME PHONE:
Seto, Samuel
4252200563
EMERGENCY-1:
HOME PHONE: URRENT
KEY ACCESS-2:
HOME PHONE:
CITY . YES NO
BUSINESS
P1
El
EMAIL:
LICENSE
-
INITIAL INSPECTION DATE
PERSON CONTACTED: -N. -4L-
NAME OF INSPECTOR:
7//
Date Last Serviced:
Emerald Pire
Fire Spfinkler Specialists
11021 Cramer Rd. KPN - Gig Harbor, WA 98329
Office (253) 857-2056 - Fax (253) 857-2312 - Local 699 Contractor
AUTOMATIC SPRINKLER SYSTEMS
(One System per Report)
40"tA P'l ncy'&'XsAY�_ \N- gt)-nayi8 M V02b 7b 1'� ve,
Occupan N e:
'Cy
fZJ < —
Responsible Person: P h o n e
Building Owner: F Phone Number:
Date of Inspection: Type of Inspection: Quarterly 0 Annual Other E]
r, r )4
Testers Name (Please Print): S 0_�) WA State FSCC# _L�q_ 0 ��2_
1
Trip test Q2.1r.0 or full flow) conducted: .................................... .............
Yesz
No E]
System tripped in seconds.
2.
All flow switches, supervisory switches and alarm bells tested: .....................
yesK
No F-� N/A n
3.
Alarm bell operates: .............................................................................
Yes/
Non N/A n
4.
Flow tests conducted: .....................................................................
Flow pressure: :77 psi 2-inch drain?
Yes No E]
Y65��o
................................. .....
n
5.
Systems inspected and lubricated: ..........................................................
Yes V
No n N/A E]
6.
Air compressor refills system in 3.0 minutes: ..............................................
Yesje
Non
7.
System drained and restored to normal operation: ......................................
Yeso
No n
8. Were the heat actuation devices tested on pre -action and deluge system? ..... Yes El No [] N/A 71
rWr�ET �SYSTE ANT' FREEEE6*S*fiA4,Tested at
W
I Trip test conducted-.
................................................................... I ....... Yes No E]
iz
Static pressure: psi Flow pressure:_75—psi 2 inch drain? ....... Yes / N4"/A E]
T_
2. Flow switches, supervisory switches and alarm bells tested: ..................... Yese No F-1 N/A F-�
3. Alarm bell operates: ............................................................................. Yes
,2� No F-1 N/A
4. Systems inspected and lubricated: ..........................................................
Ye �4
No F-1
5. - Pressure regulating valves tested: ...........................................................
YesE]
Noo
N/A2f
AUTOMATIC SPRINKLER SYSTEMS-ico'ntinued)
General
I
2.
Central Station Monitoring? ..............................................
Monitoring company name -
Location of Sprinklers
1 nool-
Yie�6
No E]
al "q ......... jtT Dasement ......... Lj Hallways ......... E] Other ........ El
3. Pumper connections and clapper valves unobstructed ....................................... Yes4�� No n
4. Sprinkler heads less than 50 years old .............................................................. Yes-R- No n
5. Sprinkler coverage is acceptable .................................................................... Yej2-1No n
6. Spare sprinkler heads are available ................................................................. YesvnNo F-1
7. Systems left in service .................................................................................. Yes+�I' No n
8. Valves are sealed or supervised ....................................................................... Yes+�r No F1
9. Signs are provided on valves ................ I ........................... ............... Yesj!::r No r-1
10. City static water pressure -psi. D-r-Y 0�
Problems Found:
0
rs
M
-1Q_*Wy_ li::,
- 1.
Corrections Made: Date Corrected: Corrected By:
SIGNATURE OF TESTER:
AGENCY. Emerald Fire PHONE: 253-857-2056
MAILING ADDRESS: 11021 Cramer Road KPN Gi H-rin— AXIA C
W"A
FIRE PREVENTION
INSPECTION REPORT
-ving Briei: Edmonds, and -idian Ave S
*�*Moff
' 1
44, . Set 12425 Met
SNOHOMISH CO. 1 1 []EDMONDS
Mountlake Terrace Everett, WA 98208 0 BRIER
FIRE Phone (425) 551-1200 El MOUNTLAKE TERRACE
DISTRIT www'.FireDistrictl.org Fax (425) 551-1272 [1 UNINCORPORATED
FREQUENCY STATION & SHIF"'
LOCATION: 21911 76th -Avenue WSuite 101 98026 2 Year 14 I&C
BUSINESS NAME: Eve Clinic ofEdmonds PHONE: 4257747723 SCHEDULED Feb 2014
DATE DUE
MAILING UFIR10'33 157
ADDRESS: 21911 76th Avenue W, Suite 101, Edmonds, WA 98026
BUSINESS OWNER: HOME PHONE:
EMERGENCY-1: Seto, Samuel HOME PHONE: 4252200563 CURRENT
KEY ACCESS-2: HOME PHONE: CITY YES NO
BUSINESS
EMAIL: LICENSE El El
PERSON CONTACTED: INITIAL INSPECTION DATE
NAME OF INSPECTOR: 3
FIRE SYSTEMS: FE 9/12
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
2
2
3
3
4 Z'
4
5
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
FINAL RE
EXTENSION
-INSPECTION
VIOLATIONS
DATE DUE:
DATE DUE:
GRANTED TO:
DATE DUE:
CITED:
PERSON
PERSON
PERSON
CONTACTED:
CONTACTED:
CONTACTED:
1
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
E:
DATE:
3
IONS
VIOLATIONS
PRE -CITATION
CITATION ISSUED
1 15
1 5
LETTER SENT
NUMBER:
4
CODE
5
2
6
2
6
DATE:
SECTION:
RETURN RECEIPT
3
7
3
7
RECEIVED
6
DISPOSITION:
7
.4
18
4
8
D ATE:
LETTER NEEDED F] YES El NO
I LETTER NEEDED F] YES [I] NO
i i
- j
FIRE DEPARTMENT COPY