23000 EDMONDS WAY (2)SNOHONTISH CO.
np-77-119TRNIq TIFF
FIREO PREVENTION
INSPECTION REPORT
Serving Briee, Eufrturtua, and 12425 Meridian Ave S
Ye EDMONDS
Mountlake Terrace Everett, WA 98208 0 BRIER
[I MOUNTLAKE TERRACE
Ph6ne (425) 551-1200 [1 UNINCORPORATED
T www.FireDistrictl.org Fax (425) 551-1272
LOCATION: 23000 Edmonds Way 98020
BUSINESS NAME: Woodway Estates
MAILING
ADDRESS: 23000 Edmonds Way, Edmonds, WA 98020
PHONE: 4257715030.
e' FREQUENCY I STATION 1, SHIFT I's
Annual 20-D
SCHEDULED Aug 2017
DATE DUE 0
591
LIFIR
BUSINESS OWNER: HOME PHONE:
EMERGENCY-1:Shibayama, Brian HOME PHONEWS-�'C CURRENT
KEY ACCESS-2: HOME PHONE: 20 CITY YES NO
EMAIL: BUSINESS
LICENSE
INITIAL INSPECTION DATE
PERSON CONTACTED: Ck-cue_ CAAI-S-01V
NAME OF INSPECTOR: wltjsrw
FIRESYSTEMS: FA12/14FE1/1-4'12:00:00AM rb (CCU
Date Last Serviced:
10�
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
AM V10C_,4'77VV!S
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-INSPEGTION
2nd RE -INSPECTION
FINAL RE -INSPECTION
EXTENSION VIOLATIONS
DATE DUE,
DATE DUE:
GRANTEDTO:
DATE DUE: CITED:
PERSON
PERSON
P RSON
E
CONTACTED:
CONTACTED:
CONTACTED:
INSPECTOR:
INSPECTOR:
2
INSPECTOR:
DATE:
DATE
3
DATE;
VIOLATIONS
VIOLATIONS
CITATION ISSUED
PRE -CITATION
1
5
LETTER SENT NUMBER:
CODE 5
6
2 6
DATE SECTION
RETURN RECEIPT
3 7
3 7
RECEIVED 6
DISPOSITION.
7
4
4 8
DATE
LETTER NEEDED C] YES F-1 NO
LETTER NEEDED [] YES NO
SNOHOMISH CO.
FIRE
DIST:
Serving Brier, Edmonds, and
Mountlake Terrace
www.FireDistrictl.org
LOCATION: 23000 Edmonds Way 98020
BUSINESS NAME: Woodway Estates
MAILING
ADDRESS: 23000 Edmonds Way, Edmonds, WA 98020
BUSINESS OWNER:
12425 Meridian Ave S
Everett, WA 98208
Phone (425) 551-1200
Fax (425) 551-1272
PHONE: 4257715030
HOME PHONE:
FIRE PREVENTION
INSPECTION REPORT
-Eleugonus-
0 BRIER
0 MOUNTLAKE TERRACE
[3 UNINCORPORATED
FREQUENCY I STATION & SHIFT
Annual 20-B
SCHEDULED
DATE DUE � Aug 2015
UFIR 0,591
EMERGENCY-1: Shibayama, Brian HOME PHONE:
KEY ACCESS-2: HOME PHONE:
EMAIL:
"'CURRENT YES NO
CITY
BUSINESS Me
LICENSE 1' -1 1:1
PERSON CONTACTED: WD MNW- - 0� 11
NAME OF INSPECTOR:
INITIAL 17NECTInN DATE
FIRE SYSTEMS: V(A-12'114-' E 1/
tv,
`DLk Box-"---*7
��
Date LastiServiced:
HAZARDSF UIND AND LOCATICINS/COMMukcATIONS
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
In our continuing effort to promote fire safety and prevention within the community, your fire department conducts
regularly scheduled "Fire Safety Survey Inspections" of allbusinesses 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. A e you
to I
will find the item(s) that were noted during. our inspection which require attention to bring them into /cpliance
with the minimum standards adopted by the above jurisdictions.
Any overlooked hazards or violations of the fire regulations does not imply approval of such con itions or violation.
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.
aJc_ LIP
CITY OF EDMONDS
INESS LICENSE APPLICATION— COMMERCIAL
FEE: $125.00
CITY CLERICS OFrk;E, BUSINESS'LICENSE DIVISION
1215 UE NORTH. EDMONDS, WA 98020 PHONE: 425.775.2525
el co w,
&71- A-.20-J67 ;t�('
OFFICE USEONLY
Custonwo
1
Year
Class
I SHO
I Data P21d I TR# I Fee Paid
Mailed Delete
rTh .4 2 -131 VTff
4
1
INSTRUC71ONS: Pkisec®rn the application In full and attach the required floor plan. Middle Initial or narne required of all
parties concerned. If no atiddle narne, please Indicate by writing NMN. Sign and return application with fee. Please advise Of -
Any change In status. Now license required If business changes location or ownership. Notification to City of Edmondi required
Ubusiness doses.
V
BUSINESS NAME
BUSINESS ADDRESS
Street Suite NO. ZIp Code
MAILING ADDRESS 11612, Pi- SW. W"dwg�4. WA. q5o,�v
Street or PO Box SufteNo. Cityj State and ZIp Code
BUSINESS PHONE NO. I WA STATE TAX ID NO. (UBI NO.)
BUSINESS E-MAIL yj-jqGgta��Hj, VM USINESSWEBSITE Nirsdeo-Ae. UIT,
kOPEiUYOWNER
Narm phone tunber
Poo -ByVjVV 1514(p - '51(A
EMERGENCY NOTIFICATION (For Premise Access In Emergency):
Last Name First Name MI Phone No.
Last
NATURE OF BUSINESS
v
NUMBER dl`�EhOLOYEES SQUARE FOOTAGE OF BUSINESS SPACE
TYPE OF BUSINESS - PLEASE CHECKTHE APPROPRIATE CATEGORY,
13 CONSTRUCTIO . N ' (3 FINANC"F_ I N-SUIR
ANOE, REAL ESTATE. (3 LANDSCAPE. HORTICULTURAL (3 MANUFACTURING - CI NO�4\1��
13 RETAIL' (3: secak&HANo PEALER M/SERVIMS 0 WHOLESALE MOTHER
AMUS8VIi�TDEVICiES�ON-PR.'E'USES? dYIES (TINO IF YES, TOTAL NUMBER
LIQU I ORSOLDOIiPRE,MISES`?: I . 3YES :"0.. G . AMB - LING? 0 YES (3/NO CIGARETTES S'OLDON PREMISES? 0 YES 0
FjLAMmAsLE OR HAzARDous mATERiALs WED -OR STORED?- eYES IF YES, ?LqASE PROVIDE LIST OF MATERIALS AND QU XTIES:
Ity,
go
PROPOSED OPENING OAXOF BUSINESS. MIA4d) 2-016 BUSINESS HOURS 0 TLLM04L
DAYS OPEN 0 SUNDAY �/MONDAY MI;TIUESDAY H/WEDNESDAY 9fHUR§DAY a FRIDAY 0 SATURDA
PARI(ING SPACES ON SITE: TOTAL —ACCESSIBLE FOR PERSONS WITH DISABILITIES,
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DIWILITIES? G<ES (3 NO;
PREVIOUS BUSINESS IUSE AT THIS ADDRESS VV0UC-T_r11A1VVk7 L*yr//C
7
X
a -%
SOLE PROPRIETORSHIP
NAME N4,& I v-�
Last I First Ml
AnnpF.q.q I I - 1% 01-0 - P I . qAJ A) rYm) I A) rl 1.4 0) W9 0
bum
APL fft. Unit I�j
city. state and zip Code
HOME PHONE NO. L20&
1 5 S-l? - 003-DOL NO. (DRIVERS LICENSE NO.) OR OTHER ID NO,
29)61
DATE OF BIRTH-447
I C17Y AND STATE OF BIRTH
COUNTRY OF BIRTHU&J�
PARTNERSHIP - PARTNER I
NAME
Last First MI
ADDRESS
street Apt. No., Unit No. City, State and Zip Code
HOME PHONE NO.( ;.�Ol NO. (DRIVERS LICENSE NO.) OR OTHER ID NO.
DATE OF BIRTH_CITY-AND STATE OF BIRTH COUNTRY OF 81
PARTNERSHIP - PARTNER 2'
NAME
Last -First MI.
ADDRESS-,,
eat
Apt.
Uj� No. City..
St�ata and 23P Coft
HOME PHONE NO.(
—DOLNO.(DRiVERSLICE-NS-ENO.)OROTHER'IONO.-
OATEOFBIRTH CITY AND STATE OF BIRTH COUNTRY OF BIRTH
I -
CORPOMTIOP
�AME OF CORPORATION —PEDER.AL -IfAX 10 NO.
CORP. ADDRESS PHONE NOJ I
Street Suite. Apt.'. Unit No- City; State and Zip Code
CORPORATE OFFICERS.
Last Name Fir6t Name
MI T196 Dati� of Birth
DOL No. (Drivers Lloonse No.) or Other ID No.
LOCAL CONTACT I L k. DOL No. (Drivers Lic. No.) or Other ID.No.
Lost Kama First Name MI Tipe Phone
'ride Date'
b. I Name — Printed
;.66- '"oa
-07YUSeONLY:..
'ANNIAG&OT!
sk�
PapITIONALUSYPERMIT.-
SUILDING:PEPT-,
D"APPROVE
0 DISAPPROVE DATE -
�IGN,ATURE.
OCCUPANT LO�b
UILDING PERMIT
___:_OOCUPANCY GR6uP
dOMMENTS
FIRE DqPT.
0 AFT;RbVE
Cl DISAPPROVE
�`SICAATURE .
.COMMEkTS
POUCE DEPT.
GAPPROVE -
0 DISAPPROVE
IGNATURE'
Comm
eq�vlte --y
)JV6. S$ _ � t�7 ' *
. �71,
-7
Common Chemotherapies in stock and quantities
DescriOgn,
Ulm
quantity
5-FU 50mg/mL (11 OmL Vial)
Vial
150
Aptinomycin D 0.5mg,viii
Vial
2
Azathioprine 50 mg Tablet
Tablet
200
Bleomycin (15 unit) I Om I Vial
Via 1.-
10
Carboplatin 10mg/mL
ML
Soo
Chlorambucil 2mg
Tabi et
30
Chloramphenicol (Viceton) Tablets 250mg
Tablet
200
Chlorimphenicol, tablets I gram
Tablet
100
Cisplatin Img/mL
MIL
150
CT- Monoclonal ti,1352
V I lal,
10
Cyclophosphamide 20mg Capsules
Capsule
50
-C : yclophosphamid I e - 20mg/mL (25mL Vial)
Vial
2
Cyclophosphamide 2 5mg
Tablet
100
Pyclophosphamide. 50mg
Tablet
350
Cyclophosphamide Inj 250mg/ml
ML
30
C�cl.opho§phamide Inj 60mg/ml(1 Oml vial)
ML
60
Cytarabine 100mg/ml
ML
20
Cytara'bine 20mdtmL
ML
40
Dexrazoxane (Zinecard) 250mg Vial
Vial
1
T
Dexrazoxan6'(Zihkaed) 506mg Vial
Vial
I
Doxorubicin 2mg/mL
ML
400
Hyaluf6nidasb 150 units/ml injectable
'ML
10
Immunocidin Injectable
ML
7
L-Asparaginase 12,50OU Vial
"Vial
10
Lomustine 10mg
Capsule
100
Lomustine Img
Capsule
100
L6mustine'.2.5m'
9
Capsule
80
Lomustine 40mg
Capsule
20
Masitinib (Kinavet) 150mg tablets
Tablet
200
Maslunib"( &� '150mg tablets'
Tablet
185
Methotrexate 25mg/mL
MIL
15
Mitoxantrone 2mg/rrt�
ML
100
Mustargen I mg/mL (1 OmL Vial)
Vial
5
Mycopheno . late, , omo'caps.
-Capsule
500
Neoplasene 100 Topical
Bottle
1
�eoplasene 300.0ral'Solution 8oz
Pottle
I
Neumega 5mg Vial
Vial
1
F�alladia - 10mg
Tablet
80
Palladia 15mg
Tablet
100
P,allaidiawm'g
Tablet
175
Pamidronate 3mg/mL (I OmL Vial)
Vial
58
l5ro'ca'rbazine 64ing capiule
Capsule
20
Tamoxifen Citrate 20 mg tablets
Tablet
20
;� a - 0
58
Mg M.,.
'Vincfttine.lrnq/mL MLI 100
45
zMelanoma vaccine Each 2G
FIRE ONE INC.
:4'
107 WASHINGTON BLVD
ALGONA, WA 98001
206-575-0311 FAX 253-735-4976
BREMERTON 360-478-0428 FAX 360-782-2584
FIRE01*099KW
FIRE ALARM SYSTEM
Confidence Test Report
FIRE ALARM SYSTEM
(One System Per Report) I I Certification Given
CONFIDENCE TEST JREPAIRS�0 El RED El WHITE El GREEN
I Sprinkler Monitoring Panel? E]
Occupant Name
WOODWAY ESTATES
Property Address
23000 EDMONDS WAY EDMONDS, WA 98020-8200
Building Owner/Mgmt Co
WOODWAY ESTATES
--r425-771-5030
Phone No.
Responsible Person
IJOHN CARLSON ==E-Mail
I
Date of Inspection
12/15/2014
1 Inspection Type
121Annual C]SemiAnnual C1 Quarterly (High Rise)
Testing Technician
LINDA BALZER SFD Certification No. SFD- B00476
11-ocation of System I
Central Station Monitoring?
El YES El NO
g Company Name
L"Model
LOCAL ONLY
Control Panel Manufacturer
I EDWARDS
No.
EST-223
11-11ML IUUUt: VIULA I IUNb 1-UUNW:
INONE
CORRECTIONS MADE Date Made
(it additional room is needed, please add a separate sheet)
(iT additional room is needed, please aaa a separate
Corrected By
This certifies that this fire and life safety system has been properly inspected for reliability to cover the items listed in this report and is
consistent Wth Fire Department Fire Code standards, and that discrepancies are noted and have been reported to the building
Owner/Manager for corrective action.
Phone #
U
206-575-0311
Signature of Tester
Testing Agency
TIRE ONE INC. 107 WASHINGTON BLVD ALGONA
WA 98001
Building Rep. ORIGINAL ON FILE
Signature
The Items on the checklists below shall be Inspected and tested. This list does not constitute all of the required
Inspecting and testing of the fire and life safety system.
Alarm System
Functionality
Trouble sigEal Ai�th AC power off?
171
YE,
171
N 0
�jy�tern op es prop rly on battery backup?
ffg_
F±1
YES
El
NO
Pattery oltage NO LOAD
25.43 volts
Battery voltage FULLLOAD
24.86 volts (Sig_aals Operatin
�qharge circuit volta e
25.79 volts
System operates p
Lop§!rly qn standby ower?
El
YES
[I
NO
��gnals o grate on AC power?
El
YES
0
NO
Number of initiating circuits
3
Number of si nal circuits
3
Does alarm s -stem meet audibility standards?
21
YES
0
NO
All circuits checked for electrical supervision?
110v
E
YES
0
NO
All auxiliary equipment operates (Elevators, fans, dampers).?
121
N/A
[I
YES
El
NO
Ventilation controls operate?
[D
N/A
El
YES
Q
NO
"e to panel available?
(D
YES
El
NO
Materials and equipment needed to restore pull stations are available at the
main panel Le. glass rods,p!ates,__Keys and allen wrenches?
121
N/A
El
YES
El
NO
Operating instructions at panel?
El
YES
E:1
NO
Trouble indicators function.pLopgrly?
[D_..YES
[j
NO
Remote annunciator p��nels function p�optrly?
N/A
2]
YES
El
NO
— ,grly?
Elevator call down functions pLop
El
N/A
0
YES
r-1
NO
Test record posted at panel?
Fz]
YES
El
NO
General alarm automatic time delay
N/A (minutes)
N/A
Was a signal received at the Central Station monitoring company?
[D
N/A
[-I
YES
El
NO
Other devices (Specify)
B
N/A
[-I
YES
El
NO
System Devices
Total Number of
Units In Building
Total Number of
Units Tested
Test Results
Acceptable
Bells, horns, chimes
Voice speakers (voice clarity)
Visual alarm devices
Smoke detectors
Heat detectors
Duct detectors
Sprinkler flow switches
Sprinkler supervisory switches
Manual pull stations
Annunciator(2)
Beam detectors
Automatic door unlocks
Automatic door releases
Fire dampers
34
4
3
18
1
34
4
3—
18
1
El
El
11
El
121
21
21
21
El
El
21
21
ED
El
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
El
11
El
F±1
El
11
1:1
1:1
21
ED
E]
1:1
El
El
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
El
El
El
11
1:1
El
El
El
El
El
0
El
El
El
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Communication Equipment
Total Number of
Units In Building
Total Number of
Units Tested
Test Results
Acceptable
Phone sets
Phonejacks
Call -In signal
I
E
F±1
El
N/A
N/A
N/A
0
El
El
YES
YES
YES
El
El
Ej
NO
NO
NO
FOR OFFICE USE ONLY
Received Repairs
Scheduled Complete
Sent
FIRE ONE, INC.
107 WASHINGTON BLVD
ALGONA, WA 98001
206-575-0311 FAX 253-735-4976
BREMERTON 360-478-0428 FAX 360-782-2584
FIREO1*099KW
FIRE ALARM SYSTEM
Confidence Test Report
FIRE ALARM SYSTEM
(One System Per Report) I _ _ Certification Given
CONFIDENCE TEST El REPAIRS 70 El RED El WHrrE F±1 GREEN
I Sprinkler Monitoring Panel? p
Occupant Name
WOODWAY ESTATES
Property Address
23000 EDMONDS WAY EDMONDS, WA 98020-8200
Building Owner/Mgmt Co
IWOODWAY ESTATES
I Phone No.
425-771-5030
Responsible Person
IJOHN CARLSON
E-Mail
I
Date of Inspection
12/15/2014
Inspection Type JE]Annual
ElSemiAnnual El Quarterly (High Rise)
Testing Technician
LINDA BALZER SFD Certification No. SFD- B00476
11-ocation of System I
Central Station Monitoring?
El YES El NO
I Monitoring Company Name
LOCAL ONLY
Control Panel Manufacturer
I EDWARDS
I Model No. +-
EST-223 I
rinr- Louiiiia- viuiLm i iumzp ruumu.
CORRECTIONS MADE Date Made
(if additional room is needed, please add a separate sheet)
acianionai room is neeaea, please acia a
Corrected By
This certifies that this fire and life safety system has been properly inspected for reliability to cover the items listed in this report and is
consistent with Fire Department Fire Code standards, and that discrepancies are noted and have been reported to the building
Owner/Manager for corrective action.
Phone #
U
206-575-0311
Signature of Tester
Testing Agency
TIREONEINC. 107 WASHINGTON BLVD ALGONA
WA 98001
Building Rep. ORIGINAL ON FILE
Signature
Th e� items on the checklists below shall be Inspected and tested. This list does not constitute all of the required
Inspecting and testing of the fire and life safety system.
Alarm System
Functionality
Troubits
_�ignal with AC power off ?
YES;
0
NO
§y�tern operates ro erly on battery backup?
El
YES
El
NO
Battery volta e NO LOAD
25.43 volts
Bafte!y voltage FULLLOAD
24.86 volts ig als 0 erating)
gharge circuit volta e
25.79 volts-
Sy�tem op�rates p�operly on standb power?
El
YES
El
NO
&1l.§:ignals operate on AC power?
[21
YES
0
NO
Number of initiating circuits
3
Number of signal circuits
3
Does alarm system meet audibility standards?
F±1
YES
0
NO
All circuits checked for electrical supervision?
110v
2
YES
Q
NO
All auxiliary equi ment operates (Elevators, fans, dampers)?
F±1
N/A
0
YES
0
NO
Ventilation controls operate?
121
N/A
0
YES
El
NO
"e to panel available?
El
YES
El
NO
Materials and equipment needed to restore pull stations are available at the
main pgnel, Le. g!ass rods, p ates, keys and allen wrenches?
El
N/A
Q
YES,
0
NO
0 erating instructions at Panel?
E
YES
El
NO
Trouble indicators function,pEoptrly?
E]
YES
[]
NO
Remote annunciator panels function p�opqrly?
El
N/A
E]
YES
0
NO
Elevator call down functions pfopgrly?
N/A
El
Y�q_n NO
Test record posted at panel?
F±]
YES
0
NO
General alarm automatic time dela
N/A (minutes)
N/A
Was a signal received at the Central Station monitoring company?
F±1
N/A
[:1
YES
El
NO
Other devices (Specify)
121
N/A
El
YES
0
NO
System Devices
Total Number of
Units In Building
Total Number of
Units Tested
Test Results
Acceptable
Bells, horns, chimes
Voice speakers (voice clarity)
Visual alarm devices
Smoke detectors
Heat detectors
Duct detectors
Sprinkler flow switches
Sprinkler supervisory switches
Manual pull stations
Annunciator(2)
Beam detectors
Automatic door unlocks
Automatic door releases
Fire dampers
34
4
3
18
1
34
4
3—
18
1
El
121
0
0
0
D,
21
n,
n
11
21
E
21
[21
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
F±1
0
ID
121
El
E-]
0
El
F±1
R
El
13
1:1
0
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
0
El
1:1
El
E]
0
El
El
El
[I
1:1
El
El
El
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Communication Equipment
Total Number of
Units in Building
Total Number of
Units Tested
Test Results
Acceptable
Phone sets
Phone jacks
Call -In signal 1
[D
2
[21
N/A
N/A
NIA
1:1
0
El
YES
YES
YES
0
El
[:]
NO
NO
NO
FOR OFFICE USE ONLY
Redeived Repairs
Scheduled Complete
Sent
FIRE PREVENTION
Serving Briei: Edmonds, and 12425 Meridian Ave S INSPECTION REPORT
SNOHOMISH CO q EDMONDS
Mountlake Terrace Everet' i28208 'BRIER
FIR9 tjf __ 0 LAKETERRACE
114? 0MOUN
Phone (425) 551-120
1'-- 6 ) [I UNINCORPORATED
DISTR T wwwFireDistfict]. 17- )7a—y('4 5T, 577-1-2-7-2—�
qrg 5
FREQUENCY STATION & SHIFT
.1
LOCATION: 22WO EdnrmtidsWay 9,%2b Atinual 20-A
SCHEDULED
BUSINESS NAME: 'Waadvay EsLalm- PHONE: DATE DUE I` Auq 20-14
MAILING UFIR I,
ADDRESS: 23000 Edrmn& Way, EdrTmn&i,`WA 080210
BUSINESS OWNER: HOME PHONE:
EMERGENCY-11: FhibaVama, Brian HOME PHONE: "CURRENT
KEY�ACCESS-2: HOME PHONE: CITY YES NO
EMAIL: BUSINESS
LICENSE [A
INITIAL INSPECTION DATE
PERSON CONTACTED: \'21r
NAME OF INSPECTOR: —vu ) 0 E.1—
I HE SYS I E ME: C-A >1 I �(F "! I
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
2 'r'�4--Nt t cc— v-Jqjc_0?—D... nT-- V-- k pq'.P� P+4 t-1 II_YFl4__
3
3
4
4
5—,
5
v
61
6
7
7
1-7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
lst RE -INSPECTION
2nd RE -INSPECTION
EXTENSION
FIN -INSP
RE ECTION
VIOLATIONS
DATE DUE,
DATE DUE,
PERSON
GRANTED TO:
DATE DUE:
CITED -
PERSON
PERSON
CONTACTED-
CONTACTED,
INSPECTOR:
CONTACTED:
INSPECTOR:
INSPECTOR:
2
DATE:
E:
DATE:
3
VIOLATIONS
VIOLATIONS
CITATION ISSUED
5
5
PRE-CIATION
LETTER SENT ..........
NUMBER:
.. ---
4
CODE
5
2
6
DATE:
SECTION:
_6
RETURN RECEIPT
3
7
3
7
RECEIVED
6
DISPOSITION:
14
8
4
8
DATE:
7
LETTERNEEDED F] YES El NO
LETTERNEEDED [] YES NO
8
FIRE DEPARTMENT COPY
FIRE ONE, INC.
107 WASHINGTON BLVD
ALGONA, WA 98001
206-575-0311 FAX 253-735-4976
BREMERTON 360-478-0428 FAX 360-782-2584
FIRE01*099KW
FIRE ALARM SYSTEM
Confidence Test Report
FIRE ALARM SYSTEM
(One System Per Report) I I Certification Given
CONFIDENCE TEST IREPAIRS Ell [:1 RED Ej WHITE(' 21 GREEN
I I Sprinkler Monitoring Panol? p
Occupant Nam7e7—
WOODWAY ESTATES
z�
Property Address
1
23000 EDMONDS WAY EDMONDS, WA 98020-82016'
Building Owner/Mgmt Co
IWOODWAY ESTATES
ji�hone No.
1425-771-5030
Responsible Person
IJOHN CARLSON
JE-Mail /I
Date of Inspection
12/9/2013
linspe ion Type
El Annual
Else /I Annual El Quarterly (High Rise)
M
Testing Technician
LINDA BALZER & ERIK BARKER
SFD de/ rtification No. SFD- B00476
11-ocation of System I
ICentral Station Monitoring?
YES El NO
I Monitoring Company aarne
LOCAL ONLY
lControl Panel Manufacturer
EDWARDS
IModell No. f
EST-223
FIHF- COUF- VIOLA11ON5 HUUNU:
INONE
CORRECTIONS MADE Date Made
(If additional room is needed, please add a separate sheet)
FJJ
It additional room is needed, please add a
Corrected By
This certifies that this fire and life safety system has been properly inspected for reliability to cover the items listed in this report and is
consistent %vith Fire Department Fire Code standards, and that discrepancies are noted and have been reported to the building
Owner/Manager for corrective action.
Phone #
206-575-0311
Slanature of Tester
Testing Agency
FIRE ONE INC. 107 WASHINGTON BLVD ALGONA WA 98001
Building Rep. ORIGINAL ON FILE
Signature
The items on the checklists below shall be Inspected and tested. This list does not constitute all of the required
inspecting and testing of the fire and life safety system.
Alarm System Functionality
Trouble signal with AC power off ?
F1
YES
El
NO
Sy§teff� operates prop�rlyqn battery_�ackup?
E]
YES
[I
NO
Battery voltage NO LOAD
25.52 volts
Batte�y voltage FULLLOAD
24.74 volts (Signals Opfpting)
Char e circuit voltage
25.87 volts
System operates pro erly on standby power?
[21
YES
D
NO
A!L§�gnals op��rate on AC power?
3
YES
D
Number of initiating circuits
3
_.�[O
Number of signal circuits
2
Does alarm system meet audibility standards?
El
YES
C1
NO
All circuits checked for electrical supervision?
110v
El
YES
El
NO
All auxiliarK_qquipment operates (Elevators, fans, dam ers)?
121
N/A
0
YES
El
NO
Ventilation controls operate?
121
N/A
0
YES
EJ
NO
Key to panel available?
El
YES
E3
NO
Materials and equipment needed to restore pull stations are available at the
main panel, Le. glass rods, plates,_ke s and allen wrenches?
y
121
N/A
0
YES
EJ—N—
NO
Operating instructions at panel?
El
YES
E]
NO
Trouble indicators function_p op
L _'�Irly?
R
YES
n
NO
Remote annunciator panels function roperly?
PLI
[:1
N/A
E]
YES
0
NO
Elevator call down functions pLopqrly?
0
N LA
0
YES
E]
NO
Test record posted at panel?
F±]
YES
El
NO
General alarm automatic time delay
N/A (minutes)
2
N/A
Was a signal received at the Central Station monitoring comp�ny?
F±1
N/A
0
YES
El
NO
Other devices (Specify)
[D
N/A
(--]
YES
[:1
NO
System Devices
Total Number of
Units in Building
Total Number of
Units Tested
Test Results
Acceptable
Bells, horns, chimes
Voice speakers (voice clarity)
Visual alarm devices
Smoke detectors
Heat detectors
Duct detectors
Sprinkler flow switches
Sprinkler supervisory switches
Manual pull stations
Annunciator(2)
Beam detectors
Automatic door unlocks
Automatic door releases
Fire dampers
34
4
3
18
1
33
4
3
18
1
11
El
0
El
El
El
El
El
El
F-1
21
21
121
121
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
El
E]
E1
El
El
El
0
El
121
El
El
0
0
11
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
El
0
11
11
1:1
1:1
E]
[--]
0
[:]
0
El
E]
E]
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Communication Equipment
Total Number of
Units In Building
Total Number of
Units Tested
Test Results
Acceptable
Phone sets
Phone jacks
Call -In signal
El
121
121
N/A
N/A
N/A
0
0
El
YES
YES
YES
0
[I
El
NO
NO
NO
FOR OFFICE USE ONLY
Received Repairs
Scheduled Complete
Sent
SNOHOMISH CO.
FIRE
DIST-eq
Servi Brier, Edmonds
moiintlake Terrace, and
FTthe Town of Woodway
www.FireDistrictl.org
ly LOCATION: 23000 0 Way-% Edmonds 98020
BUSINESS NAME: Woodway Estates
12425 Meridian Ave S
Everett, WA 98208
Phone (425) 551-1200
Fax (425) 551-1272
FIRE PREVENTION
INSPECTION REPORT
0 EDMONDS
0 BRIER
0 WOODWAY
[I MOUNTLAKE TERRACE
[I UNINCORPORATED
UENCY I STATION& SHIFT)
nual 20-D
LED
)E � Aug
MAILING FIR 591
ADDRESS: 23000 Edmonds Way, ,
�PUSINESS OWNER: HOME PHONE:
Email:
__HOMEPHO
EMERGENCY-1: Shibayama, Brian NE: CURRENT. YES NO
KEY ACCESS-2: HOME PHONE: CITY
BUSINESS
LICENSE
INITIAL INSPECTION DATE
PERSON CONTACTED:
NAME OF INSPECTOR:
Ime A_
FIRE SYSTEMS: FE �21 I-?-&
PHONE: 4257715030
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
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
GRANTED TO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
- CONTACTED:---
PERSON
CONTACTED:
7
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
7
RETURN RECEIPT
RECEIVED
6
4
'8
4
8
DATE:
DISPOSITION:
7
LETTER NEEDED E] YES El NO
LETTER NEEDED C] YES El NO
8
FIRE DEPARTMENT COPY
Fire One, Inc. Confidence Test Report
107 WASHNGTON BLVD.
ALGONA, WA 98001
(206) 575,0311 FAX (253) 7354976
BREMERTON (360) 478-0428 FAX (360) 782-2584
(One System per Report)
CONFIDENCE TEST El REPAW
Occupancy Name:__AQ0A0 "A ge-6*06
Aa .1,602-0
Occupancy Address: 0 rw blkA
Building Owner:
Phone Number: S
Responsible Person: AP6 CA0AACV\ Phone Number:
T_
Date of Inspection: Inspection. Type: Annual Quarterly (High- Rise Only)
Testers Name (Please Print):
Location of System:
Central station monitoring?
Yes No*
Monitori . ng company name:
Control panel manufacturer
Model Nuniber:
Problems Found: (If additional room is needed, please add a separate sheet)
Corrections Made.-, Date Corrected: Corrected By:
(If additional room is needed, please add a separate sheet)
This certifies that this fire and life safety system has been properly inspected for reliability to cover the items listed in this report
and is consistent with Fire Department Fire Code..standards, and that discrepancies are noted and have been reportedto the
building Owner/Manager for corrective action.
Signature of Tester: 4,017 Phone # 1_06,5 TS - b 5
Testing Agency: 6zvLe &
Spia, CJA. q8co I
Mailing Address:
.7
Building Representative (Signature)
The items on the checklists below shall be inspected and tested. This list does not constitute all of the required inspecting and
testing of the fire and life safety system.
System, Devices
Total Number of
Units in Building
Total Number
Units -Tested
Test Results
Acceptable
1.
Bells, Horns, Chimes
N/A [I
Yes $J7 No
3.
W
Smoke Detectors
A�I
N/A ED
es-9 No,
15.
021 ft -`1
Duct Detectors
Ml-
-
N/Al2O Yes No [3
7.
Sprinkler Supervisory Switches
M ME
r'p:
MTM I U n I WIM. I
N/A
Yes JV No C]
Ill.
Automatic Door Release
N/A'
Yes No
E-
Communication Equipment
Total Number of
Total Number Test Results
Units in Building
Units Tested Acceptable
11 Phone Jacks
NIAV Yes No
;e
S,
I
Fire One, Incl.
Office (253) 735-4976 Fax
givd.
Algona, WA 98001
1314tME I RTO:N (360) 478-0428
viner Lj
2. Type of system.: . Addressa ble Conventional Other
3., Local Fire Deparbent Monitored? Yes C] NojM
4. Monitoring Agency. Telephone: Ki (A
5. Test ReceWd Monitoring A§ehdy? fq (pt Yes Lj No Lj Monitoring A=unt
6. Mb. of Initiating Cii0ft.. No. of Signaling Circuits:
BATTERY TEST - 11 DURATION: #1 #2 43 #4 NOTES
7. Static Battery Voltage
r8Battery Voltage Under Load
. w/Simal Davinas 6oaratino
9. Change Circult Vdtage 1 2 2-1 1 1' -j
CONTROLPANELCHECKS
SATISFACTORY
CHECK.
NOTES;
Yes
No,
I NIA
10. Trouble Signal WAC Power Off
11. AD Circults Operate Satisfacto on Standby (Battery) Power
ry
12. All Circub Operate Satisfactory on AC Power
13. All Circuits Checked for EleclAcal Supervision.
Cl
13
14. Control Panel Checks Made Per Manuhtcturers Instructions
0
15. AD andliary Equipment, Operates
*16. Alarm Delay Function (ff installed):Operates Propedj
El
11
17. Panel Key AvailatAe
50
El
11
18. Operating Insholions at Panel*
55
El
El
19. Test/Service Record at Fire Alarm Control Panel
0
W@m&AddrwsofFzdIItT. 40A,�11201,A r�;-.A�f
Dab: I'L- 12-z 1
a:3000 z
a.,*-Q WIINITNSTED.
SATISFACTORY
TYPE OF EQUIPMENT
MANUFACTURING
CHECK
& MODEL
OREM
T 751.7i'Tin
MEMO-
��s
..
�"s
INF71 �il
-�s
FE
so
i MEN
sswffry!�M=
A" 'A
M-7 -1
Visda[DeAces. �4.
Audio/Msual Nvkw
Public Addrew.S"m
Fire man - ft. ones -7
ElevalofRecall., Phae I
Pha�e 11
Auto Dobr,Relem
Fail Sab'DooWnlock,
Vefifidon-.Conlrds
. Tj 1 13
Sprinkler FlowSwitches
Sonkler Tamper Swftes
Sprinkler SuperVi
isM Swkbhes 71
Electric AJarrn BeWMotor Gong
OHM I D I
THIS IS TO CERIFY THAT THIS FIRE ALARM SYSTEM HAS BEEN PROPERLY,,INSPECTED
F . OR RELIABILITY TO COVER THE r . I -Ems LISTED IN THIS REPORT 16 CON818 . TENT
WITH.FIRE ALARM MAINTENANCE STANDARDS.
Signature of Omer or Represerift":
Signature of Fwe Alarm Representative: <4 Lh 0(a A gel till ,
Discrepancies: %-Ah",
Corrections Made:
Date Corrected: BT. Cert #
PAGE 2 OF 2
FIRE PREVENTION
Serving Brier, Edmonds
12425 Meridian Ave S
INSPECTION REPORT
1 SNOHOMISH CO.
Mountlake Terrac�,and
TIRE .
Everett, WA 98208
o .4 11
O'EDMONDS
0BRIER
Q,w66DVVAY
t h e To w n oj, woo'' a"'y'
DIST Rt*4'fwiii�.,,Twww.FireDistrictl.org
Phone (425) 551-1200
0-46UNTLAKE TERRACE
Fax,-(4�5) 551-1272
0 UNINCORPORATED
e- FREQUENCY
STATION & SHIFT_`�
LOCATION: 23000 Edmonds Way
365
20,,B
BUSINESS NAME: Woodway Estates
PHONE: 42577'15030
SCHEDULED
DATE DUE II'
MAILING PO Box 713
UFIR � 428 8054-
ADDRESS: Mercer Is land
'98040
BUSINESS OWNER: Shibayama, Brian
HOME PHONE:
ACTIVE
EMERGENCY-1: theshib@verizon.net
HOME PHONE:
"'CURRENT
KEY ACCESS-2:
HOME PHONE:
CITY Y S 0
BUSINESS
LICENSE
PERSON CONTACTED:
INITIAL INSPECTION DATE
NAME OF'INSPECTOR:
16(111
F)RE FA 12108 FD LkBx
SYS I EM.S:
ANNUAL
14 R Ul
RDS F
DS FOUND AND LOCATIONS COMMUNICATIONS
0
2
3
z
.4
A,
5
5
6
6
q
7
.11'AGREE TO COR THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
,PT
1st RE -INSPECTION
2nd RE -INSPECTION
FINAL RE -INSPECTION
EXTENSION
v16LATIONS
DATE DUE.
DATE DUE.
GRANTED TO,
DATE DUE:
CITED:
PERSON
PERSON
PERSON
CONTACTED:
CONTACTED:
CONTACTED:
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIOP4��'fe
VIOLATIONS
PRE -CITATION
CITATION ISSUED
5
1 15
LETTER SENT
NUMBER:
4
CODE
5
2
6
2
6
DATE:
SECTION:
RETURN RECEIPT
3
7
3
7
RECEIVED
6
DISPOSITION:
14 18
4
.8
DATE:
LETTERNEEDED [] YES El NO
LETTERNEEDED C] YES El NO
FIRE DEPARTMENT COPY
.. .........
CITY OF EDMONDS
121 5TH AVENUE N. - EDMONDS, WASH.IN6tOf4�98020 (425) 771-0215
FIRE DEPARTMENT
Al t
LOCATION: 23000 Edmonds Way
BUSINESS NAME: Wooc6ay Estates
MAILING PO Box 713
FIRE'PREVENTION
SAFETY SURVEY
PHONE: 4257715030
FREQUENCY STATION & SHIFT
20 A
SCHEDULED
DATE DUE 1� (18/0 110
UFIR I� 428 8054
ADDRESS: Mercer Island 98040
BUSINESS OWNER: Shibayama, Brian tfE)ME PHONE:,
Cei-L 14Z!0�L115-
EMERGENCY-1--- theshib@*efiz-errnet HOME PHONE: (42-5�) —11 r3c)750
KEY ACCESS-2: / c-at-qcrvr�-r , t%jv'-� HOME PHONE:
ACTIVE �
PERSON CONTACTED: N-)-O) INITIAL INSPECTION DATE
Z-/ v7 /I c)
NAME OF INSPECTOFf-. -y-o0ta" - Tr-NLIL�J
.—I - - ---
FIRE FA 12/09(rD LkBx FE J�L� �(-Q
SYSTEMS: t2-1(tv 0I1— ANNUAL!
FIRE DEPARTMENT COPY
it
'i
Fire One. Inc.
Fire Protection Service/Sales
107 Washington Blvd
Algona, Wa 98001
Seattle: (206) 575-0311 * Bremerton (360) 478-0428
TO
Edmonds Fire Department
121 5th Avenue North
Edmonds, WA 98020
Letter of Transmittal
Date 12/8/2010 jJob No.
Attention
RE: Test Reports
WE ARE SENDING YOU El Attached 0 Under separate cover via
El Shop Drawings 13 Prints D Plans El Test Forms
E3 Copy of Letter 13 Change Order El Other
the following items:
El Specifications
COPIES
DATE
NO.
DESCRIPTION
1
12/06/10
23000 Edmonds Way/ Woodway Estates
THESE ARE TRANSMITTED as checked below.
For Approval El For Your Use El As Requested El For Review And Comment
REMARKS
COPY TO: File (Office), Property or Management Co. SIGNED:
Edmonds Fire Department
If enclosures are not as noted, kindly notify us at once.
107 WASHNCiTON BLVD
ALGONA. WA 98001
.(2D6) .1�75-0311 FAX (153) 735-4976
*BRtMMT0N C360) 478-0428 FAX (360) 782-2584
(One* system per Riport)
.I'CONFMENCIE TEST
AA,1
occupancy'Name:
v
W
Lpecl-Upancy Arab.
*7 ne Numiber". z
ho
BuRding Owner. JP6 BOX
phone Number..
gesponsible permn: M-4,2 r CA"
/Z Ae,-� T a#4;nn Tvne: AMBURI Quarteriy Mvh Rise 0111y)
Dai of Imwecuc.11: L
Testers Name (PleMe Print):
LoCILtion Of System: naf'l
ito:1.7ing? . yes E] No Monitoring compan3t name:.
Central station mon
Control panel rnanufacturer Model Number
ProblemsFouln (I�additionAl room is needed, please add a sepmzte sh tet)
7AfMj1 pvt4". S. 'Y .140�3 old, .
- .-.7. 7- -1 -
Date Corrected: Iz 0� Cor re ctea Br.
Corrections M2de: yp__5
rTf;AriitifmRI room is neecled, pl�ase add a srpmzte sheet)
I V 7-4*4y9 Rif 794�y
T,his certifies that th . fire.and life safety sy&tem has been properly insppcted -for reliability to the 1�nu Ested in this report
ndards, and that dise.rep2ncies are noted and haveien reportW to the
and is consistent -with Fire Department Fire Code Sta
building OwnerAV[ann-ft' for CO)rrecvve action.
,er
Phone # 206-575-611
S ature of Te&-trr-. 5�
Testing- Aggeucy-_ Fire One, Inc
Mailing Address: 107 Wash n-
(Signature)
Renresentative
JL UC ALCIUS on rjav cur-ciu—b L-1- n-a-
tesfing of the fire and We safety system.
Alarm System FunctionalitY
Trouble signal with AC power off?
..Yes 87
No LJ
INOE]. .
System opemtes properly on battery backup?
Battery volfage (no load) EW
MV01ts
Battery vol�age (fiL loa4) 4P
Volts (sigialt qeTating)
Charge -circuit voltage C-ge -�- Z4 0. 9:
Yes
No[]-..
SySt--M op=ateS properly On standby- P*ower?
. . . . . I '; .
yes;R':
..No
A-U.signals operatp� on AC power?
Number of initiating circuits
Number of sign* Circuits .
Yes'g.
;'Noo
Does alarm �ystem meet audibility standards?
e g,
Y s
'N' 00
cal,
An Circuits checked for electri supenris.ion?
.
No7
All ilLiciliary eqiipment operates (Elevators, fans, danjp;rs),7.
N/A.2
Yes
No[3
Ventilation controls operate? -
Yes5a
NoD
Key -to panel available?
Yesg
N
Operating instructions afpanel?
.
Yes
No
T roulAem'di c a'aors function properly?
NJA
Yes[]
No
kernote Annunciai6r Panels function properly?
N�A'W'
Yes[]
No
Elevator'Call Down functions properly?
Yes
No
Test record posted'at panel?
.
N/A
General alarra automatic time delay .(minutes),
Yes'[]
N29
0ther Devices (specify)
_j
System Devices
Total Number of
Units in Builffing
Total,Number
Units Te9ted
Test II.esulb
Acceptable
I.:
Bells, Horns, Chimes
A-1-L
N/A LJ Yes 9V
NO 13
2.
Voice Speakers (Voice Clarity)
N/A;8Z Yes D
No [I
3.
Sn�pke Detectors
N/A 0 Yes Ir
NO 0
4.
Heat Detectors
N/A;9 Yes 0
No 0
5.
Duct Detactors
N/A W Yes 0.
N 0`0
6.
Sprinkler Flow S,%itches
-N/A-W.'Yes D
No [I
7.
Sprinkler Sup=-Asory Switches
N/A T Yes D
No D
8.
Visual Alarm. Devices
N/A 0 Yes )r
No D
9.
Manual PulI Stations
N/A 0 Yes X
NO D,
10.
'Aiftornatic Door Unlocks
N/A Yes D
No 0
11.
Aiftoniatic Door kelease'
N/A Yes 0.
NOD
12.
Beam Detf--ctors
N/A 0 Yes Ej,
No D
Communication Equipment
Total Numb er
'Total Number
Test Resubs
Units in Buildine,
Units Tested
Acceptable
12. Phone Sets
113.
-NAIX-Ye—s 090-13—
Phone Jacks
N/A;I YeSD NOD.
14.' CaH-in Sigmal.
N/A X Yes 0 No D
N