21911 76TH AVE W STE 202 (2)F—FA
" 111111111-0151) -7(,P-fh 19dr— L-) S7-CZo2_ FIREPREVENTION
Serving Brier, Edmonds, and 12425 Meridian Ave S INSPECTION REPORT
0 EDMONDS
Mozintlake Terrace Everett, WA 98208 C1 BRIER
Phone (425) 551-1200 0 MOUNTLAKE TERRACE
[I UNINCORPORATED
0111 A AWA.0 A www.FireDistrictl.org Fax (425) 551-1272
21911 76 th Avenue W Suite 202 98026
LOCATION:
BUSINESS NAME:'T-ye Surgery Of-EllffieePi&— PHONE: 4252759972
MAILING 21911 76th Avenue W, Suite 202, Edmonds, WA 98026
ADDRESS:
BUSINESS OWNER: Seto, Samuel HOME PHONE:
e' F%ffNCY
STA�IENd SHIFT
SCHEDULED
DATE DUE �
Fe32017
LIFIR
lbf
Seto, Samuel 4252200563
EMERGENCY-1: HOME PHONE: CURRENT
KEY ACCESS-2: HOME PHONE: CITY YES NO
BUSINESS F_�
EMAIL: LICENSE I I El
I,— INITIAL INSPECTION DATE
PERSON CONTACTED: WL,+L-) —Co L-,,2 e-kihF
NAME OF INSPECTOR: p4� -7- vytc^-ev —t
�-IKL `)TS I tMti: 'et-Wr,3
Date Last Serviced:
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
1
2 .2.
3 3
—4
5 5
6 6
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
In our continuing effort to promote fire safety and prevention within the community, your fire department conducts
regularly scheduled "Fire Safety Survey Inspections" of all businesses and multi -family occupancies in the Cities
covered by Snohomish County Fire District 1.
You are to be congratulated on the relative good condition of your occupancy in regards to fire safety. Above y
will find the item(s) that were noted during our inspection which require attention to bring them into compliance
with the minimum standards adopted by the above jurisdictions.
Any overlooked hazards or violations of the fire regulations does not imply approval of such conditions or violatio
11 kf",.
If you require additional information or to schedule a re -inspection for Edmonds, call (425) 775-7720; for
Mountlake Terrace or Brier, call (425) 744-6231.
Serving Brier, Edmonds,qand
SNoH6N11S'Hc'0. Mwintlake Terrace
F1 - E
DISTR w,ww.FireDistrictl org
LOCATION: 2 1911 76 th Avenue W Suite 201 98026
Custom Dental Care
BUSINESS NAME:
, Lj
FIRE PREVENTION
1242 . 5 Meridian Ave S
INSPECTION REPORT,
Everett, WA 98208
0 EDMONDS
0 BRIER
Phone (425) 551-1200
0 MOUNTLAKE TERRACE
0 UNINCORPORATED
Fax (425) 551-1272
4257440598
PHONE:
MAILING
21911 76th Avenue W, Suite 201, Edmonds, WA 98026
ADDRESS:
BUSINESS OWNER: HOME PHONE:
e- FRECYENCY STJ6
20, SHIFT
SCHEDULED Feb 2017
DATE DUE II'
593157
UFIR
EMERGENCY-1: Youg,Jane
HOME PHONE: 4252388307
KEY ACCESS-2:
HOME PHONE:
[—�URRENT
ITY
BUSINESS
YES NO
Ea", F-1
EMAIL:
LICENSE
PERSON . CONTACTED: rl 40
INITIAL INSPECTION DATE
NAME OF INSPECTOR:
L
STEW-7—FE
D ate Last Serviced:
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
L rf
Alf�V L,)- 0��
t c
2.
2
3
- . . 1 4
6
- 1 7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
'Ist RE -INSPECTION
2nd RE -INSPECTION
I t
FINAL RE -INSPECTION
EXTENSION i VIOLATIONS
DATE DUE.
DATE DUE:
GRANTEDTO: I
DATE DUE: CITED:
PERSON
PERSON
PERSON
CONTACTED.
CONTACTED
CONTACTED.
2
INSPECTOR.
INSPECTOR:
INSPECTOR:
DATE
DATE-
3
DATE:
VIOLATIONS
VIOLATIONS
CITATION ISSUED
PRE -CITATION
1 5
1 5
4
LETTER SENT NUMBER
CODE 5
2
2 .6
DATE SECTION.—
RETURN RECEIPT
3 .7
3 7
RECEIVED 6
DISPOSITION
i8�
4 �8
D E
�T
LETTER NEEDED YES NO
LETTER NEEDED YES NO
i 8
FIRE PREVENTION
Serving Brier, Edmonds, and 12425 Meridian Ave S
... INSPECTION REPORT
SNOHOMISH CO.'
OEDMONDS
Mountlake Terrace
FIRE
Everett, WA 98208
0 BRIER
I
DISTRIUT
Phone (425) 551-1200
Fax 551-1272
0 MOUNTLAKE TERRACE
0 UNINCORPORATED
www.FireDistrictl.org
(425)
FREQUENCY
STATION & SHIFT
LOCATION: 21[411 76 th AvenUe' W Suite 201 98020
2 Year -14
1 16-C
BUSINESS NAME: Custom Dental Care
PHONE: 4257440598
SCHEDULED Feb 2014
DATE DUE
MAILING
UFIF49.'3 157
ADDRESS: 21911 76th Avenue W, Suite 201, Edmonds, VVA 98026
BUSINESS OWNER:
HOME PHONE:
EMERGENCY-1: YoUg, Jane
HOME PHONE: 4252388307
CUR -RENT
KEY ACCESS-2:
HOME PHONE:
CITY YES NO
BUSINESS
EMAIL:
LICENSE
PERSON CONTACTED: Al
INITIAL INSPECTION DATE
NAME OF INSPECTOR: Li
A_) —1
-7-17- 2-01
FIRE SYSTEMS: FE
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
LA (I-) �,o D m\ e: A (ijy L) /q I,
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:
1
EXTENSION
GRANTEDTO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
I
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
E:
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
DATE:
DISPOSITION:
7
\1 LETTER NEEDED F] YES NO
LETTERNEEDED E] YES El NO
8
I I FIRE DEPARTMENT COPY
"I t, Lli_ .
-7
FIRE PREVENTION
INSPECTION REPORT
Serving Briei; Edmonds, and
12425 Meridian Ave.,5I:A.'�'�
..
SNOHOMISH CO
FIRE
Mountlake Terrace
Everett, WA 98208
EIEDMONDS
El BRIER
T
Phone (425) 551-1200
Fax 551-1272
[1 MOUNTLAKE TERRACE
El UNINCORPORATED
,DISTRI
www-FireDistrictLorg
(425)
FREQUENCY
I STATION & SMFF`�
LOCATION:
21911 76 th Avenue W Suite 202 98026
2 Year 14
16-C
BUSINESS NAME:
Eye Surgery of Edmonds
PZNE� 4252759972
SCHEDULED Feb 2014
DATE DUE
MAILING
37
UFIF493 lf,
ADDRESS:
21911 76th Avenue W, Suite 202, Edmonds, 'NA 98026
BUSINESS OWNER:
-0m, 5mpi tt'k I
HOME PHONE:
EMERGENCY-1:
Seto, Samuel
HOME PHONE: 4252200563
KEY ACCESS-2�.
HOME PHONE:
CITY YES
BUSINESS
V
NO
El
EMAIL:
LICENSE
PERSON CONTACTED:
r�/v\ I L q
INITIAL INSPECTION DATE .
NAME OF INSPECTOR:
Do t",) i- )A) C)L 0 1
—]
FIRE SYSTEMS:
FE k—!-L3 :� —5
HAZARDS FOUND AND LOCATIONS /COMMUNICATIONS
0 V AA � T c1n C-)
2
2
3
3
4
4
5
5
6
6
7
7
1 AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1st RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTEDTO:
FINAL RE -INSPECTION
DATE DUE:
VI OL A41IONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
1 5
VIOLATIONS
1 5
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
2
6
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED
6
4
8
4
'8
DATE:
DISPOSITION:
7
LETTER NEEDED [-] YES NO
LETTER NEEDED F] YES C3 NO
8
FIRE DEPARTMENT COPY
Serving Brier, Edmonds 12425 Meridian Ave S
SNOHOMESH CO.
Mountlake Terraceand Everett, WA 98208,
FIRE IMOM I
':"-fhe Town of Woodway Phone (425) 551-pyoo"
STR Twww.FireDistrictl.org Fax (425) 551-1272
LOCATION: 4 / 1* 4P2 02,
AIM
BUSINESS NAME: PHONE:
9
f�_z
MAILING
ADD4SS:
FIRE PREVENTION
INSPECTION REPORT
*EDMONDS
1 BRIER
0 WOODWAY
0 MOUNTLAKE TERRACE
0 UNINCORPORATED
QUENCY I STATION 1, SHIFT
)ULED
)UE 1' /0
PY5
BUSINESS OWNER: aa, -5�eh HOME PHONE:
EMERGENCY-1: HOME PHON425- CURRENT
-KEYACCESS-2: HOME PHONE: CITY YES NO
BUSINESS
LICENSE El
INITIAL INSPECTION DATE
PERSON CONTACTED:
NAME OF INSPECTOR:
(4 , sq'k 4 -If 5; e"a <e -
HAZARDS FOUND AND LOCATIONS / COMMUW-CATIONS
A)b vlotAf7m& -FD c.��Ivb
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
lj7�f
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:
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
1 5
VIOLATIONS
1 5
PRE -CITATION
LETTER SENT
CITATION. ISSUED
NUMBER:
2
6
2
6
DATE:
CODE
SECTION:
5
�3
7
3
7
RETUAN RECEIPT
RECEIVED
,8
4
8
:1
DATE:
DISPOSITION:
tLETTER =NEEDED F] YES NO]
LETTER NEEDED [I YES NO
8
FIRE DEPARTMENT COPY
At
FIRE PREVENTION
Serving Briet; Edinonds
12425 Meridian Ave S
INSPECTION REPORT
SNOHOMISH CO.
4�11
0 EDMONDS
Mountlake Terraceand
Everett, WA 98208
0 BRIER
the
'DIST,FIRE Town of Woodway
RI T
Phone (425) 551-1200
E]WOODWAY
0 MOUNTLAKE TERRACE
www.FireDistrictl.org
Fax (425) 551-1272
[1 UNINCORPORATED
FREQUENCY
STATION & SHIFT-'
LOCATION: 21911 76th Ave W
202
365
16 A
BUSINESS NAME: Eye Surgery of Edmonds
PHONE: 4252759972
SCHEDULED
DATE DUE 0 02101112
MAILING 21911 76th Ave W,1202
UFIR 1, 593 2157
ADDRESS: Edmonds
98026
BUSINESS OWNER: Seto, Samuel
HOME PHONE: 4252200563
EMERGENCY-1: Seto, Grace
HOME PHONE: 4252200564
CURRENT
KEY ACCESS-2:
HOME PHONE:
CITY YES NO
BUSINESS
LICENSE
PERSON CONTACTED:
INITIAL.INSPEC 0
NAME OF INSPECTOR: f
;71L
FIRE
FE
SYSTEMS:
ANNUAL
HAZARDS FOUND AND LO IONS COMMUNICATIONS
Alo
2
2
3
4
4
5
5
6
6
7
7
-1 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:
I
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
r4
8
DATE:
DISPOSITION:
7
LETTER NEEDED [] YES NO
LE=TTER =NEEDED [I YES El NO
8
FIRE DEPARTMENT COPY
Emerald Pire
Fire Spfinkler Specialists
11021 Cramer Rd. KPN - Gig HarborWA 98329
Office (253) 857-2056 - Fax (253) 857-2312 - Local 699 Contractor
AUTOMATIC SPRINKLER
(One System per Report)
Occupancy Address: Zl-"�'11 te2�0_57 0 c c u p a n c y N a rn e:
Responsible Person: C? Phone Number:
Building Owner: Phone Number:
Date of Inspection'
Type of Inspection: Quarterly Annual-
,E�- Other El
Testers Name (Please Print): WA State FSCC# J"kS;-7-
71Z 65 X/o
DRY SYSTEM/PRE-ACTION SYSTEM:
1'..
Trip test (dry trip or full flow) conducted: ..................................................
Yes
System tripped in seconds.
2.
All flow switches, supervisory switches and alarm bells tested- . ........... ........
Yes
No,Ej'
N/A El
3.
Alarm bell operates: ......................................... ..................................
Yes
No E]
N/A E]
4.
Flow tests conducted: ....................... ..................................................
Yes El
No El
Flow pressure: s -inch drain? ................................ I .......
Yes El
No El
5.
Systems inspected and ricated: ..........................................................
Yes El
No El
N/A El
6.
Air compress efills systern in 30 minutes: ..............................................
Yes E]
No El
7.
Syst rained and restored to normal operation: .....................................
Yes El
No EJ
Were the heat actuation devices tested on pre -action and deluge system? .....
Yes EJ
No El
N/A D
I SYSTE NTI-FREEZE SYSTEM: Tested at
1 .
Trip test conducted: ...............................................................................
Yes �4-
No E]
Static pressure: �t�_/p�i'Flo'W*pressure: 90 * psi . 2Anch drain? .......
. Yes Lg�-
Nb;Ej
VA'E]
2.
Flow swit . ch . es supervisory switch es and alarm bells tested: ........................
Yes Z'
No F-1
N/AE]
3.
Alarm bell operates: .............................................................................
Yes2f-
No El
N/A El
4.
Systems inspected and lubricated: ..........................................................
Yes?9-
No El
5.
Pressure regulating valves tested: ...........................................................
Yes 0
No E]
"'Q,
N/A r
>110\
AUTOMATIC SPRINKLER SYSTEMS (continued) i
General:
�7-
1 Central Station Monitoring? .......................................................................... Ye4A,- No F-1
Monitoring company name
2. Location of Sprinklers
100% ......... FJ,-' Parking ......... E] Basement ......... E] Hallways ......... E] Other ........ El
71�
3. Pumper connections and clapper valves unobstructed ....................................... Yes.R- No F�
4. Sprinkler heads less than 50 years old ............................................................. YesW No R
5. Sprinkler coverage is acceptable .................................................................... Yes E;�.- No Ej
6. Spare sprinkler heads are available ................................................................. YesR- No E]
7. Systems left in service .................................................................................. YeSPI No F]
8. Valves are sealed or supervised ...................................................................... Yes r7- No F-1
le
9. Signs are provided on valves ......................................................................... Yes,0- No
10. City static water pressure eg _psi.
Problems Found:
Corrections Made: Date Corrected: Corrected By:
SIGNATURE OF TESTER,�
AGENCY: Emerald Fire PHONE: 253-857-2056
MAILING ADDRESS: 11021 Cramer Road KPN, Gig Harbor,WA 98329
Emerald Pir*'e
Fire Sprinkler Specialists
11021 Cramer Rd. KPN - Gig HarborWA 98329
Office (253) 857-2056 - Fax (253) 857-2312 - Local 699 Contractor
AUTOMATIC SPRINKLER SYSTEMS,,,fer/7!Tp-'ie(g.-,?,/,��
(One System per Report)
- '* A -
Occupancy Address: &VZIL oc-r-IS2, 0 c c u p a n c y N a m e.174,-
Responsible Person: Phone Number:
Building Owner: Phone Number:
Date of Inspection: 17ZC;� Type of Inspection: Quarterly F-1 Annual Other
Testers Name (Please Print)- WA State FSCC# 411111�e3
DRY SYSTEMPARE-AL I MIN bYb I tryl:
r full flow) conducted: .................................................. Ye�o Noo
1 Trip tesr���
System.tripped in se.co.nds.
2. All flow switches, supervisory switches and alarm bells tested: ..................... Yes;p� Noo N/A E]
3. Alarm bell operates: ............................................................................... Yes Rf' No E] N/A E]
4. Flow tests conclucte
�d ........................................................................... Yes No
0- El
Flow pressure: psi 2-inch drain? ....................................... Yes'o- No E]
5.
Systems inspected and lubricated: ..........................................................
Yese' No E]
N/A E]
6.
Air compressor refills system in 30 minutes: ..............................................
Yes 01
No E-]
7.
System drained a nd restored to normal operation: .....................................
Yes, P�'
No F-1
8.
Were the heat actuation devices tested on pre -action and deluge system? .....
Yes E]
No Ej
N/A
WET SYSTEM/ANTI-FREEZE SYSTEM: Tested at
ITrip
test conducted: ................................................................................
Yes M
N
Static pressure: _ps.i Flow pressure: -psi. /2 inch cl.rain? .......
es F]
No 0.
N/A E]
2.
. Flow switches, supervisory switches and alarm b ed: ......................
Yes []
No E]
N/A
3. .
Alarm bell operates: .............. ..... ......................................................
Yes El
No EJ
N/A El
4.
Systems inspec nd lubricated: ..........................................................
Yes EJ
No EJ
5.
Pr re regulating valves tested: ...........................................................
Yes E]
NoE]
N/A E]
AUTOMATIC SPRINKLER SYSTEMS (continued)
General:
1. Central Station Monitoring? ..........................................................................
Monitoring company.name
I. _'_ Location of Sprinklers
1-1 - - .0
41Y
Yesj�f - NoE]
100% ... : ..... E] Parking......-_-,. I I Basement ......... F� Hallways ......... E] Other ......... E]
3.
Pumper connections and clapper valves unobstructed .......................................
Yes;;�-
NoE]
4.
Sprinkler heads less than 50 years old ..............................................................
Yes;;4-
No E]
5.
Sprinkler coverage is acceptable ....................................................................
Yes �p
No E]
6.
Spare sprinkler heads are available .................................................................
Yes Pk
No El
7.
Systems left in service ...................................................................................
Yes.��
No
8.
Valves are sealed or supervised ......................................................................
Yes
,;A,
No El
9.
Signs are provided on valves .........................................................................
Yes
No E]
10.
City static water pressure -psi.
Problems Found:
Corrections Made: Date Corrected: Corrected By:
SIGNATURE OF TESTER: — '� la'o'-'
.AGENCY: Emerald Fire _2�r PHONE: 253-857-2056
MAILING ADDRESS: 11021 Cramer Road KPN, Gig Harbor, WA 98329
CITY OF EDMONDS
121 5TH AVENUE N. - EDMONDS, WASHINGTON 98020 - (425) 771-0215
FIRE DEPARTMENT
4SIS 9 z
t . I S
LOCATION:
21911 761h Ave W
BUSINESS NAME:
Eye Surgery of Edmonds
MAILING
21911 76th AveW #202
ADDRESS:
Edmonds
BUSINESS OWNER:
Seto, Samuel
EMERGENCY-1:
Seto, Grace
KEY ACCESS-2:
FIRE PREVENTION
SAFETY SURVEY
MEA
PHONE: 4252759972
98026
HOMEPHONE: 4252200563
HOMEPHONE: 4252200564
HOME PHONE:
FREQUENCY
STATION & SHIFT
3 6 15
16 C
SCHEDULED
0' 02/01,110
DATE DUE
LIFIR o. 593
2157
PERSON CONTACTED:—C ftl-�A 41� A,-) S S INITIAL INSPECTION DATE
NAME OF INSPECTOR:
FIRE
SYS3TEM S: T-j ANNUAL
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
i t-3 'I_:
ENTER CODE ONLY ONCE 1�
VIOLATION CODE
2
2
3
3
4
4
5
5
6
6
7
7
8
8
list 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
7
4
18
4
8
DATE:
DISPOSITION:
8
�UETTER NEEDED C] YES No
LETTER NEEDED 0 YES NO
FIRE DEPARTMENT COPY