23632 HWY 99 STE T (2)7"
Z-3,& 3 Z H-r&""4Y '9 9 Srg :FIRE PREVENTION
'SNOHON I IISH Serving Brier, Eumunds, and
12425 Meridian Ave S
IN�SP ORT
J�CTION REP
Mountlake Terrace
FIRE
Everett, WA 98208
ETEDMONDS
El BRIER
, 11 4 * I
DISTIft T
Phone (425) 551-12190
Fax 551-1272
El MOUNTLAKE TERRACE
[1 UNINCORPORATED
wwwFireDistrictLo rg
(425)
LOCATION: 23632 Highway.99 SuiteT98026
FREQUENCY
Annual
STATION & SHIFT
20-B
s.,4 T J Max #852
BUSINES N
4257745001
PHONE:
SCHEDULED Sep- 2017
.
DATE DUE
MAILING
FIR 0 63
ADDRESS: 23632 Highway 99, Suite T, Edmonds, WA 98026
BUSINESS OWNER: Taunt, Daylon
HOME PHONE: L4?-. 7 76 9 ZV,�
EMERGENCY-1:The TJX CO., Inc
HOME PHONE:
CURRENT
KEY ACCESS-2:
HOME PHONE: 20
CITY YES No
BUSINESS F__j
EMAIL:
LICENSE
PERSON CONTACTED: L)
,
I
7>,jr�--k-
INITIAL INSPECTION DATE
/-z
—19
NAME OF INSPECTOR: PIC I V.- -
1
(-a
FIRESYSTEMS: AS11/lPFAll 16
Date Last Serviced: 6 R iih,
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
P5 C1dtt*e,0( t
L-r /Pl
oorv%
2 (VV V1 -'0 ss
2
3
4
5
6
3
4
5
6
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS Yr-1
lst RE -INSPECTION
2nd RE -INSPECTION
i FI�ACRE-INSPECTION
EXT SION
Sl( VIOLATIONS
.PATE DUE-
DATE DUE:
INNTED TO
DATE DUE. CITED:
PERSON
PERSON
PERSON
CONTACTED,
CONTACTED
CONTACTED:
INSPECTOR
INSPECTOR,
INSPECTOR 2
DATE
DATE
DATE 3
VIOLATIONS
VIOLATIONS
CITATION ISSUED
PRE -CITATION
1 5
1 5
LETT NUMBER 4
',ER,SENT
CODE 5
2 '6
2 6
DATE SECTION
RETURN RECEIPT
3 7
3 7
RECEIVED 6
DISPOSITION
8
4
DATE.
LETTER NEEDED [I YES Cl NO
LETTER NEEDED YES NO
8
Serving Br e'r
i , Edmonds, and 12425 Meridian Ave S
SNOH10)
Moz4nflake Terrace Everett, WA 98208
F RE Phone (425) 551-1200
STR T www.FireDistrictl.org Fax (425) 551-1272
" TEnQIUEN
LOCATION: 23632 Highway 99 Suite T 98026 n ICY STff r SHIFF
T J Max #852 4257745.001 SCHEDULED Sep 2016
BUSINESS NAME: PHONE: DATE DUE
lbJ
MAILING 23632 Highway 99, Suite T, Edmonds, WA 98026 UFIR 0
ADDRESS:
BUSINESS OWNER: V1 HOME PHONE:
The TJX CO., Inc 5083903517
EMERGENCY-1: HOME PHONE: CURRENT
KEY ACCESS-2: HOME PHONE: CITY YES NO
,E - N ONTACTED: LA
'S C
0
NAMEO FCINSPECTOR:
KLSy.5lF-gS7-AS9/14FA1'0/15FE10/13
ate Last Serviced: ll�-
IV 4 S qh�� 9
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS'
I ;J"(I'�� L) VI VILA_, C KMIS
5 7
4�,
X
4
5
6
7
FIRE PREVENTIO N
INSPECTION REPORT
0 EDMONDS
0 BRIER
0 MOUNTLAKE TERRACE
[I UNINCORPORATED
�] 1:1
INITIAL INSPECTION DATE
9
1
f2
3
4
5
6
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X ll�T V
Ist RE -INSPECTION
2nd RE -INSPECTION
IAL RE -INSPECTION
EkNSI9 VIOLATIONS
DATE DUE:
DATE DUE:
GRANTED -TO: _J�F
DATE DUE: CITED:
PERSON
PERSON
PERSON
F?NTACTED,
CONTACTED:
CONTACTED
INSPECTOR: W//v5lpv
INSPECTOR:
2
INSPECTOR:
DATE:
DATE
3
DATE:
VIOLATIONS'
VIOLATIONS
PRE -CITATION CITATION ISSUED
I FI&Aj) 11-16 5
5
LETTER SENT NUMBER, 4.
2 6
2 6
CODE 5
DATE SECTION
RETURN RECEIPT
7
3 7�
RECEIVED, :6
DISPOSITION
4 8
4 8
7
DATE
LETTER NEEDED YES 0 NO
LETTER NEEDED YES NO
Confidence Test Report
1002 CENTRAL AVE NORTH
KENT WA 98032
PHONE: 253-852-1962
FAX: 253-852-2049
FIRE ALARM SYSTEM
(One System per Report)
Certification Given
RED
YELLOW
WHITE
CONFIDENCE TEST�
0
REPAIRS
Sprinkler Monitoring Panel?
Occupancy Address- 23632 Highway 99, Edmonds,WA98026
Responsible Person
First & Last Name- Manager
Responsible Person
Address, City, State, Zip:
Date of Inspection:
10-09-2015
Testers Name
(Please Print): Richard Narayan
Identification
Number:
Central station monitodng? Yes El No ED
Monitoring Required? Yes El No r_1
System Make: Radionics
OccupancyName: TJ Maxx #852
Phone -Number: _(425) 774-5001
Responsible Party
E-Mail Address
Inspection Q u a rte rly (High-rise Only)
Frequency/Type: Annual
Nicet
Number: - 131392 / N-07104 / 0912-E
System Location Electrical Room
Monitoring Vector Security
Company Name:
System Model: _D7024
FIRE CODE VIOLATIONs FOUND: (if additional room is needed, please add a separate sheet)
CORRECTIONS MADE: Date Corrected:
(if additional room is needed, please add a separate sheet) Nicet Number:
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 Authority Having Jurisdiction standards, and that
discrepancies are noted and have been re he building Owner/Manager for corrective action.
Z I
Signature of Tester: �(_� 7 Phone # (253) 852-1962
Building Representative (signature)
23632 Highway 99, Edmonds,WA 9j
00�-- OCT 15 2015
Fire Alarm Systems
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. Refer to the Fire Department Code for inspecting and testing requirements.
Alarm Svstem Functionali
1.
Trouble signal with AC power off?
Yes U
No El
2.
System operates properly on battery backup?
Yes [:1
No El
3.
Battery voltage (no load) 26.6 volts
4.
Battery voltage (full load) 25.9 volts (signals operating)
5.
Charge circuit voltage 27.1 volts
6.
System operates properly on standby power?
Yes El
No El
7.
All signals operate on AC power?
Yes El
No El
8.
Number of initiating circuits Addrewable
9.
Number of signal circuits 2
10.
Does alarm system meet audibility standards as accepted?
Yes Ei
No El
11.
All circuits checked for electrical supervision?
Yes,7
No!.!
12.
All auxiliary equipment operates (Elevators, fans, dampers)?
N/A
YesEl
No [::,I
13.
Ventilation controls operate?
N/A
Yes
No,' j
14.
Key to panel available?
N/A F7
Yes
No
15.
Materials and equipment needed to restore pull stations are available at the
N/A
Yes
No7]
main panel, e.g. glass rods, and plates; keys and alien wrenches, etc?
16.
Operating instructions at panel?
Yes
No
17.
Trouble indicators function properly?
Yes
No j-
18'.
Remote Annunciator Panels function properly?
_N/A,
Yes
19.
Elevator Call Down functions properly?
N/A
Yes
No'-'
20.
Test record posted at_panel?
Yes
.-No
21.
General alarm automatic time delay (minutes)
N/A
22.
Was a, signal received at the Central Station monitoring company?
N/A F-j
Yes E:
No L-
23. Other Devices (Specify)
Yes,'-,
No 1-1
System Devices
Total Number of
Units in Building
Total Number
Units Tested
Test Results Acceptable
24. Bells, Horns, Chimes
9
9
N/A L'
Yes X
No E
25. Voice Speakers (Voice Clarity)
N/A LX
Yes [I
No �7-
26. Visual Alarm Devices
10
1:0
N/A E
Yes X
No EI
27. Smoke Detectors
1
1
N/A ::1
Yes,X]
No [I
28. Heat Detectors
N/A LK
Yes E�
No L,
29. Duct Detectors
6
6
N/A 177
Yes X
No.-
30. Sprinkler Flow Switches
2
N/A X
Yes E
No
31. Sprinkler Supervisory Switches
2
N/A X
Yes ::1
No
32. Manual Pull Stations
4
4
N/A
Yes
No
33. Annunciator(s)
N/A
Yes
No'-,
34. Beam Detectors
N/A
Yes
NoE
35. Automatic Door Unlocks
N/A
Yes
No
36. Automatic Door Release
N/A E
Yes E
No E
37. Fire Dampers
N/A
Yes
No
Communication Equipment
Total Number of Units
in Building
Total Number Units
Tested
Test Results Acceptable
38. Phone Sets
N/A Yes No F
39. Phone Jacks
N/A Yes No
40. Call -in Signal
N/A Yes' NoF-I
Fire Alarm Systems Page 2 of 2
SN01
FIN
D
FIRE PREVENTION
Serving Briet; Edmonds, and 12425 Meridian Ave S INSPECTION REPORT
0 EDMONDS
Mountlake Terrace Everett, WA 98208 0 PRIER'
Phone (425� 551-1200 0 MOUNTLAKE TERRACE
wwwFireDistrictl.org Fax (425) 551-1272 __ OUNINCORPORATED
FREQU�NCY�,
STATION & SHIFT
LOCATION:
23832 Highmay 99 Suite T 03026
Ailflual
20-C
BUSINESS NAME:
I J May 48 r.2 PHONE:
42,M)4600 I
SCHEDULED
DATE DUE I` Solo 2014
MAILING
UFIR I,
ADDRESS:
23&12 1 lighway 30, SaiLc 1, Ed mon&, W A 99026
BUSINESS OWNER:
C'Imi, Anita HOME PHONE:
EMERGENCY-1:
I tic I SX CO., Inc HOME PHONE:
5503M- M617 CURRENT
KEY AtCESS-2:
HOME PHONE:
CITY
YES NO
BUSINESS
In
0
LICENSE
PER CONTACTED:
INITIAL
SPECTION DATE
AMIL
N VOF-INSPECTOR:
�-IHE SYS R-MB'. FA JW13 FE lW13
HAZARDS FOUNqAND LOPATIONS COMMUNICATIONS
1146 1 OL-) 1 6 :001 1 z,
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
lst RE -INSPECTION
DATE DUE.
2nd RE -INSPECTION
DATE DUE.
EXTENSION
GRANTEDTO,
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED.
PERSON
CONTACT-ED:
PERSON
CONTACTED:
PERSON
CONTACTED:
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
1 5
VIOLATIONS
5
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2
6
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED
4
8
4
8
DATE:
DISPOSITION:
LETTER NEEDED C] YES El NO
LETTER NEEDED [-] YES NO
8
FIRE DEPARTMENT COPY
x 3013 3rd AVE NORTH FIRE DEPARTMENT INVOICE# 73
SEATTLE, WA 98109
(206) 284-1721 Confidence Testing ACCOUNT #
(800) 223-FIRE
(206) 284-1769 FAX AUTOMATIC SPRINKLER SYSTEM DATE
AAA.FIRE.COM
Address ';�3 1 q ;L 2klv City: /-�'�_IKI 6 ;&/4 Zip Code
Occupied as: -NA C<-.)(
Building Owner:
Ph.# llr-:r a W A, W_
%#%, I z -1 41J
Address: City: Zip Code:
Date of Inspection: 00 Type of Inspection: nnu Other
t4&c_ ( Ak W43p-Certification# r4p�—I—nvt—_C5,
Tester's Name (PLEASE PRINT) ;41
DRY SYSTEM
'No
1.
Trip test (dry trip) conducted:
Yes 4-�
System tripped in /0 seconds
2.
All flow switches, supervisory switches & alarm bells tested
Yes ----No N/A
3.
Alarm Bell operates:
Yes ::;;:�o N/A
4.
Flow tests conducted:
Static Pressure psi
Yes --'--No
Flow pressure :::� psi
2 inch drain?
Yes __.e:��No
5.
Systems inspected and lubricated
Yes ,�No
6.
Air compressor refills system in 30 minutes
Yes :�:�No
7.
Systems drained and restores to normal operations
Yes —
8.
Were the heat actuation devices tested on pre -action and deluge systems?
Yes — No_ N/A
WET SYSTEM
--<o
1.
Flow test conducted:
Yes
Static Pressure psi
Flow Pressure psi
2 inch drain?
Yes
---No
Other
2.
Flow switches, supervisory switches & alarm bells, tested
Yes
e-"No
N/A
3.
Alarrn bell operates:
Yes
el� 0
5-'No
N/A
4.
Systems inspected and lubricated:
Yes
— N
N/A
5.
Pressure regulating valves tested:
Yes
— No
N/A
GENERAL
1.
Central Station Monitoring?
Yes
----No
Name of Company
2.
Location of Sprinkler:
Basement Hallways As Designed Others
3.
Pumper connections and clapper valves unobstructed
Yes
-"'No
4.
Sprinkler heads less than 50 years old
Yes
---No
5.
Spare sprinkler heads are available
Yes
--No
6.
Systems left in service
Yes
No
7.
Valves are sealed or supervised
Yes
8.
Signs are provided on valves
za_
Yes
No
9.
City Static Water Pressure - psi
PROBLEMS FOUND:— 1,,!e e :��s
CORRECTIONS MADE:
Date corrected
THIS IS TO CERTIFY THAT THE VRINKLER SYSTEM HAS BEEN PROPERLY TESTED AND INSPECTED FOR RELIABILITY TO COVER
THE ITEMS LISTED IN TH1rSRT::",/ ,V
4 A111tr —
SIGNATURE OF TESTE SF&LICENSE #
Fom #: 8304
Ad
6125�
IN
W,
Confidence Test Report
1002 CENTRAL AVE NORTH
KENT WA 98032
PHONE: 253-852-1962
FAX: 253-852-2049
SPRINKLER — DRY SYSTEM—
Certification Given
(One System per Report)
RED
L]
I YELLOW
Lj
I WHITE
CONFIDE CE TEST REPAIRS I L]
Occupancy Address: 23632 highway 99 Edmonds,Wa. 98026
Occupancy Name: TJ Maxx
Responsible Person Tim
First & Last Name:
Phone Number: 425-774-5001
Responsible Person
Responsible Party
Address, City, State, Zip:
E-Mail Address
Date.of Inspection, 1-3-13
Inspection
FrequencyfType Annual 0
Testers Name
(Please Print): Jason Tucker
Nicet Certification
Number: N 116973
Identification Number
(Required):
System Location: Stock room
Central station monitoring? Yes No[:]
Monitoring Required? Yes NoEl
Monitoring Vector
Company Name:
System Make: Star
System Model: A
SEATTLE FIRE CODE VIOLATIONs 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) Nicet Certification Number:
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 Code standards, and that
discrepancies are noted and have been reported to the building Owner/Manager for corrective action.
Signature of Tester:
Phone # 253-852-1962
Building Representative (signature)
23632 highway 99 Edmonds,Wa. 9
OL
Sprinklers - Dry Page 'I of 2
The items on the checklists below sh * all be inspected and tested. This list does not constitute all of the requireT'
inspecting and testing of the fire and life safety system. Refer to the Fire Code for inspecting
and testing requirements.
General
1.
Trip test conducted?
Yes IX-1
NOD
2.
17
S ttqm�tripoecl in 12.- second Time to ins�&Ctors. test:
y Trip point,
3.
Main Drain and Inspector's Drain flow test conducted.?
F7
Yes Z\j
NoF
4.
.. . .. ........
Static pr 55
essure:: psV* Flow pressure: si
5.
.. .. .......
Number of Sprinkler Heads?
6.':
�-i'rich d'r'ain?:' Other
�e`
0
7.
1 Flow switches, s u per 11 v . i 11 sor . y switch . es and alarm bel I s t es; ted? N/A
F-1
Yesm
NOD
8.
Alarm,'bell o0orElt�s?.:.::. N A`
.,Ye
9.
Air compressor refills system in 30 minutes or less?
Yesm
Non
io;
vices:tp$ on: pre''-n';ad16h'a'n'd ��,N/k
He"a'tiai.iiaticin'' 66"d g,
nx
:,:es
Y
No
11.
System inspected and lubricated?
YesFXj
No
D
Valves a r6sea lied '6r's'u oerviseV
17X
No
13.
Signs are provided on valves?
Yes ZNJ
NOH
.1 1 4�,'�
Pumper conne . c . t . ions and"clk)ber valvesunobstructed'and. turd: free'ly?.�
Ye.s.FX
NO
15.
Sprinkler heads replaced or successfully sample tested in last 10 years?
Yeso
No 1:1
Date of last test:
.16.::-.
Sprinkler. coverage �s, accebtabl.6
17. Proper number of spare sprinkler heads available with appropriate wrench for Yes No
each?
left.in'service :Yes
X j:' �,,.NoLj'
r
19.
System gauges replaced or calibrated within the last 5 years?
Yesm
NOR
Year changed: 2012
20-
?
Sp'ri'nkl'e"'r-head's�.f'r'e'�e'-ot corrosion,� paint, ob'strudio'ns':6nd/o�.-r.),h�si66l.d amageij�,-
S:
L
N. OFT
21.
System drained and restored to normal operation?
Yes 1^1
No El
2L:'��:�:Was'cle-'bris
-V� found in th6 F ire De'partmeht�Cbnnection (FDC)?-
Yes El
NON.,
23.
Was the Fire Department Connection (FDC) back flushed in the last 5 years?
Yes lZ^-j
No
Date of last back flush 2012
24.
. .... . . ...
Was a signal received at the Central Station monitoring company? N/A 0
es1z
NOD
25. Is the hydraulic nameplate installed and visible on riser, if.No then Yellow Tag. Yes F7 No
(Ref: NFPA 25 5.2.7)
26. Was an internal pipe and valve inspection performed within the last 5 years? Date Yeso No 1:1
Performed 2012
23632 highway 99 Edmonds,Wa.
Sprinklers - Dry Page 2 of 2
A
A,
q -�]W- �-j
'P
Confidence Test Report
1002 CENTRAL AVE NORTH
KENT WA 98032
PHONE: 253-852-1962
FAX: 253-852-2049
SPRINKLER — WET SYSTEM
Certification Given
(One System per Report)
RED
[j
I YELLO���
I WHITE
CONFIDENCE TEST REPAIRS--F-
Occupancy Address: 23632 highway 99 Edmonds Wa. 98026 Occupancy Name: TJ Maxx
Responsible Person Tim er: 425-774-5001
First & Last Name: Phone Numb
Responsible Person Responsible Party
Address, City, State, Zip: E—Mail Address
Date of Inspection: 1-3-13 Inspection Annual
Frequency/Type. El
Testers Name Nicet Certification
(Please Print): Jason Tucker Number: N 116973
Identification Stock room
Number: * System Location:
Central station monitoring? Yes NoE] Monitoring
Monitoring Required? Y es R-1 NoO Company Name: Vector
System Make: Star System Model: F
FIRE CODE VIOLATIONs 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) Nicet Certification Number:
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 Code standards, and that
discrepancies are noted and have been repo ed to the building Owner/Manager for corrective action
Signature of Tester: Phone # 253-852-1962
Building Representative (signature)
23632 highway 99 Edmonds,Wa. 9E
Sprinklers - Wet Page 1 of 2
1�c � '. 1k
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. Refer to the Fire Code for inspecting
and testing requirements.
General
in and Inspector's Drain ow' ...-Yes
M a%in Drai fl test 6.on',diucted?
FX1
N..o
2.
Static pressure: 75 P. s. i. Flow pressure: 55 P. S. i.
:3.:
Number of Sprinkler'He*ads:
4.
Full Flow? 2" DrainFV-]
f 7/1
Yes [/\I
No
5.
F16W'switches. supervis.ory..switches and alarm bells tested?. �,::N/A...
Yes 7K,
N9M
6.
Pressure regulating valves tested? N/A [/\I
Yes
NoEl
7.
Ala Il ateO N A
rM. q ,oper .......
Ye s
No! .
8.
System inspected and lubricated?
Y,e.s,Z ......
NoD-
.9
-,Va ves: are. sea ed or: supe,rviseidZ::�:,�:
Y es FX
N o
-0.
10.
Signs are provided on valves?
Yes VN
No-O...
A-l!
PUmper con , -�and, clapper valves: unobs*tr'ucted.,and- turh,frpely?
hections
Yes.0
No
12.
Spr I inkl e . r coverage is acceptable?
Yes F�
NoD
"I 3-':HaV.e
the.sprinkler heads been -replaced or successfully sample test, inthe.
Yes M.:
"N6 F
last 50 years? Date of last test:
14.
Proper number of spare sprinkler heads available with appropriate wrenches
M
Yes r/\1
No F7
for each?
es
No
1 6
S . y I stem gauges replaced or calibrated within the last 5 years?
Yes
NoD
.Yearchanged: 2012
,17
St�rihklet he6ds',fe64-.,o :corrosion, pa,inti, obstructions, and/cir:physical,
... ... ...
No
datrf ' 0
Age
18.
Was debris found in the Fire Department Connection (FDC)?
Yes
NoLLI
.1 9,�::
Was , the. Fite' Department Connection.(FDC).. back flushed within'th.e. last. 5.,
Ye s, L/L\j
No
-,ye
ars7, Date of last back flus h.. 2012
20. Was an internal pipe and valve inspection performed within the last 5 years? Yes M NoD
Date Performed 2012 V\l
23632 highway 99 Edmonds,Wa. 9
Sprinklers - Wet Page 2 of 2
01re =31 I== 0-401
01/20/2012 13:15 2538727277 ARCHER PAGE 02/07
7855 S. 206th Street Kent. WA ";18032
Ph 253.872.7222 Fax 253.872-7277
ARCHER,",3v ARCHEI*219DR
C 0 N S T R U C T 1 0 N , I N C
FIRE PROTECTION DIVISION
AUTOMATIC FIRE SPRINKLER INSPECTION REPORT
PROPERTY NAME: TJ MAXX #0852 DATE: 01/03112
ADDRESS: 23632 Hwy 99, Ste 1200 AHJ: Edmonds
CITY: Edmonds STATE! WA ZIP. 98026 INSPECTOR: Steve ElIllsor
CENTRAL STATION MONITORING CO: ADT PHONE# 206-443. -9620
PROPERTY OWNER.- ATTENTION:
OWNER ADDRESS:
TYPE AND NUMBER OF SYSTEM(S) BEING TESTED:
WET DELUGE
DRY ANTI -FREEZE
PRE -ACTION FIRE PUMP OTHER
CLASS OF SYSTEM:
LIGHT X ORDINARY X EXTRA
1.GENERAL CONDITIONS
YES
_N/A
NO
A. IS THE BUILDING OCCUPIED
B. is OCCUPANCY THE SAME AS PREVIOUS INSPECTIONS
7-00-
*
C. ARE ALL FIRE SPRINKLER SYSTEM$ IN SERVICE
V
D. IS BUILDING COMPLETELY SPRINKLED
—
E. ARE ALL NEW ADDITIONS AND BUILDING CHANGES PROPERLY PROTECTED
V
F. 15 ALL STOCK OR STORAGE A MINIMUM OF 18" BELOW SPRINKLERS
V
G, WAS PROPERTY FREE OF FIRE SINCE LAST INSPECTION
2. CONTROL VALVES
A. ARE ALL MAIN SUPPLY VALVES OPEN
8. ARE ALL OTHER VALVES WITH IN THE SYSTEM IN PROPER POSITION
C. ARE CONTROL VALVES IN GOOD CONDITION
D. ARE CONTROL VALVES EASILY ACCESSIBLE
E. DO CONTROL VALVES HAVE INDICATING SIGN ATTACHED
F, OPERATED THROUGH FULL RANGE OF MOTION, LUBRICATED AND RETURNED TO NORMAL
0, ARE CONTROL VALVES LOCKED, SEALED OR SUPERVISED
3. PUMPS & FIRE DEPARTMENT CONNECTIONS
A, PUMPS AND TANKS APPEAR TO BE IN GOOD EXTERNAL CONDITION
B. ARE TANKS AT PROPER PRESSURE AND/OR WATS R LEVELS
V
C. ARE FIRE DEPARTMENT CONNECTION VISIBLE AND ACCESSIBLE
D. ARE FIRE DEPT. CONNF-CTIONS IN SATISrACTORY CONDITION, COUPLINGS FRECE, CAPS IN PLACE
E. LOCATION OF FIRE DEPARTMENT CONNECTION CHECK VALVE
Riser
F, FIRE DEPARTMENT CONNECTION CHECK VALVE BEEN INSPECTED IN LAST 5 YEARS
4. WET SYSTEMS (SEE SECTION N13)
A, DATE 5 YEAR INTERNAL EXAM COMPLETED ON ALARM VALVE AND VALVE TRIM
B. DATE 5 YEAR OBSTRUCTION INVESTIGATION WAS LAST PERFORMED
C. HAVE ANTI -FREEZE SYSTEMS BEEN TESTED AND LEFT IN SATISFACTORY CONDITION
D. TEMPERATURE RESULTS OF ANTI -FREEZE TEST
E. ARE ALARM VALVES, WATER FLOW INDICATORS AND RETARD CHAMBERS SATISFACTORY
F. GAUGES CALIBRATED OR LESS THAN 5 YEAR$ OF AGE
Unknown
Unknown
_/
-i-.
N/A
G. IS SYSTEM HYDRAULICALLY DESIGNED AND NAMEPLATE ATTACHED TO SY5Tr:m RISER
IH, DOES BUILDING APPEAR TO BE PROPERLY HEATED FOR WET SYSTEM$ PROTrCTING BUILDING
0 r. U4 11111111111111111110BUIPRIV01) PARMA 9 1 1�G1&vfTM__:r6 =01
01/20/2012 13:15 2538727277 ARCHER PAGE 01/07
ARCHER
Y(CONSTRUCTION INC.
7855 S, 206th Street, Kent, WA 98032 P (253) 872-7222 F (253)-872-7277
DATE: 1/20/2012
TO: Edmonds Fire Depart
FAX: 425-775-7721
FROM: Lisa Wallis
RE: Annual Inspection Reports & Five Year Inspections
Attached are the reports for: TJ rvlaxx 40852 23632 Highway 99 Suite 1200 Edmonds WA
Thank You
Lisa Wallis
01/20/2012 13:15 2538727277 ARCHER PAGE 03/07
DRY SYSTEMS (SEE SECTION Al
IS DRY PIPE VALVE IN SERVICE AND IN GOOD CONDITION
IS AIR PRESSURE AND PRIMING WATER LEVEL SATISFACTORY
13 AIR COMPRESSOR IN GOOD CONDITION AND FREE OF CONDENSATION
WERE LOW POINTS DRAINED ONTY:
ARE QUICK OPENING DEVICES IN SERVICE
DATE 5 YEAR OBSTRUCTION INVESTIGATION WAS LAST PERFORMED
HAS THE DRY PIPE VALVE BEEN TRIP TESTED AS REQUIRED
DATE THE LAST FULL TRIP OF DRY SYSTEM WAS PERFORMED
GAUGES CALIBRATED OR LESS THAN 5 YEAR OF AGE
IS SYSTEM HYDRAULICALLY DESIGNEID AND NAMEPLATE ATTACHED TO SYSTEM RISER
VALVE HOUSE AND HEATER IN SATISFACTORY CONDITION
Unknown
Unknown
16. ALARMS
A. MECHANICAL WATERFLOW DEVICE OPERATE$ SATISFACTORY
B, ELECTRIC ALARMS OPERATES SATISFACTORY
C. SUPERVISORY SIGNALS TEST SATISFACTORY
0. ALARM COMPANY RECEIVE SIGNALS
E. SIGNALS RESTORED AND SYSTEM BACK IN SERVICE
17, SPRINKLERS AND PIPING
ARE SPRINKLERS IN GOOD CONDITION, NOT LEAKING, FREE OF CORROSION, FOREIGN MATERIAL.
PAINT, DAMAGE AND SPRAY PATTERN NOT OBSTRUCTED
ARE STANDARD RESPONSE SPRINKLERS LESS THAN 50 YEARS OLD OR SAMPLE TESTED
ARE FAST RESPONSE SPRINKLERS LESS THAN 20 YEARS OLD OR SAMPLE TESTED
DRY SPRINKLERS LESS THEN 10 YEARS OLD 013 SAMPLE TESTED
IS APPROPRIATE NUMBER OF EXTRA SPRINKLERS AND WRENCH(5) READILY AVAILABLE
IS CONDITION OF DRAIN VALVES, CHECK VALVES. PRESSURE GAUGES SATISFACTORY
IS CONDITION OF PIPING, HANGERS, EARTHQUAKE BRACING AND SUPPORTS SATISFACTORY
IS HAND HOSE ON SPRINKLER SYSTEM SATISFACTORY
SECTION #13 WET SYSTEMS
DRAIN
STATIC
FLOW
STATIC
VALVE
TRIM
SYSTEM#
MAKE
SIZE
MODEL
SIZE
PSI
PSI
PSI
COND.
COND.
1W
Star
6
F
2
75
50
70
Good
Good
SECTION #14 DRY SYSTEMS
DRAIN
STATIC
FLOW
STATIC
VALVE
TRIM
SYSTEM#
I M�AKE
SIZE
MODEL
SIZE
PSI
PSI
PSI
COND.
COND.
1D
Star
31
A
1 1/4"
75
so
70
Good
Good
SECTION #14 DRY SYSTEMS
WATER
AIR
AIRTRIP
TRIPTIME
ORIFICE
TIME TO
TEST
SYSTEM#
SERIAL#
O.O.D.
DRY TRIP
PSI
PSI
PSI
AT VALVE
SIZE
OUTLET
PROPERLY
NIA
NIA
Yes
75
32
15
N/A
1/21'
N/A
Yes
CONTROL VALVES
SYSTEM #
MAKE
SIZE
MODEL
OPEN
SIGN
LOCKED
TAMPER
COND.
1W
Gem
6
OS&Y
Yos
Yes
No
Yes
Yes
1D
Gem
3
OS&Y
Yes
Yes
No
Yes
Yes
Sri, =f, IMNM- lag]
01/20/2012 13:15 2538727277 ARCHER
PAGE 04/07
EXPLANATION OF ANY "NO" ANSWERS OR DEFICIENCIES FOUND
i-1 Gauges are over 6 years and need calibrating or replacement
#2 Internal investiRation of wet & dry system has not been performed in the last 5 years
#3 5 year backf1ush of FOC through underground has not been performed in the last 5 years
#3 Unclear if Dry heads are over ten years and require replacement of sample testing, Need a lift to veriN
ADJUSTMENTS OR CORRECTIONS MADE
1 - Gauges replaced
2 - internal pipe exam completed on wet-& d!X sy§tems,
3 - Backflush completed on FDC
DATE CORRECTIONS MADE 1 t1 7/2012 BY WHOM Stephen Ellisor
THIS IS TO CERTIFY THAT ALL THE ABOVE SYSTEMS HAVE BEEN PROPERLY TESTED AND INSPECTED PER
N.F.P.A 25 STANDARDS FOR THE RELIABILITY TO COVER THE ITEMS LISTED IN THIS REPORT AND ARE
CONSISTENT WITH THE MANUFACTURES REQUIREMENTS.
SIGNATURE OF TESTER
DATE: 1/3/12
Washington State Cert1floation Number 5773-IT-01 I 1 `10 ICY.)
01/20/2012 13:15 25313727277 ARCHER PAGE 05/07
ARCHER16
C 0 INISTRUCT 1 0 N, I INIC
7855 S. 206th STREET KENT WA. 98032 - 253-872-7222 - FAX 253-872-7277 - ARCHEI*219DR
REPORT OF INTERNAL CONDITION OF SPRINKLER PIPING
PROPERTY NAME: TJ MAXX #0852
DATE: 1/17/2012
ADDRESS: 23632 Highway 99, Ste 1200
AHJ: Edmonds
CITY: Edmonds STATE: WA ZIP:
98026
TYPE OF SYSTEM: WET E= DRY
DELUGE PREACTION
I. GENERAL INFORMATION I
I YES N/A
07
A. DOES THE SYSTEM APPEAR TO AE REGULARLY MAINTAINED
M 1111mn�
0
B. DOES THE SYSTEM APPEAR TO BE IN A CORROSIVE AREA
Lj ci
21
C. DATE OF LAST INTERNAL INSPECTION
Unknown
2. NOW WET SYSTEM PRE INSPECTION PROCEDURE
YES N/A
NO
A. PIPING Fii-LED WITH WATER PRIOR TO FLUSHING
B. FILLED BY TRIP TEST
Li Ld
C)
C. AMOUNT OF DEBRIS COLLECTED AT TIME OF TRIP TEST:
D. SYSTEM REMAINED WET FOR P-RIOR TO FLUSHING
3. RESULTS OF INITIAL EXAMINATION
A. TOTAL NUMBER OF CROSS MAINS EXAMINED
% OF TOTAL CROSS MAINS so
S. TOTAL NUMBER OF BRANCH LINES EXAMINED
% OF TOTAL BRANCH LINES 10
C. TOTAL FOOTAGE OF BULK MAINS EXAMINED
OF TOTAL BULK MAINS 0
0. OTHER AREAS OF SYSTEM INSPECTED
E. INTERNAL CONDITION OF WET/DRY PIPE VALVE
4. DESCRIPTION OF EXAMINATION
Removed End Cap to Cross main Very Clean Inside
Removed End Sprinkler head on Branch line All clean
S. ADDITIONAL CLEANING _j
A- IS THE SYSTEM REOUIRED TO HAVE ADDITIONAL CLEANING
No
B. RECOMMENDED FORM OF CLEANING
N/A
C. REASON FOR ADDITIONAL CLEANING
N)A
This iA to cartiflod that the WET SYST�EM
haS boon property Inspected for obstructions and internal
condition of the p1ping using the standards set forlh by N.F,P.A. 25
Name of Inspector: Steve EIllsor
Signature:
M Z, Mfts =- @Am T-WIN-41) Ow-'s-09i NOW MON JISIAILIIM-Irl 111=1 IMEW
01/20/2012 13:15 2538727277 ARCHER PAGE 06/07
ARCH.ER16-
CONSTRUCTION, INC
1[-7855 S. 206th STREET KENT WA. 98032 - 253-872-7222 - FAX 253-872-7277 - ARCHEI*219DR
REPORT OF INTERNAL CONDITION OF SPRINKLER PIPING
PROPERTY NAME: TJ MAXX #0852
DATE: 1/17/2012
ADDRESS: 23632 Highway 99, STE 1200
AHJ: Edmonds
crry: Edmonds STATE: WA ZIP:
98026
TYPE OF SYSTEM: WET E�K� DRY
DELUGE PnEACTION
1. GENERAL INFORMATION
YES N/A
NO
A. DOES THE SYSTEM APPEAR TO BE REGULARLY MAINTAINED
R1
#
0
B. DOES THE SYSTEM APPEAR TO BE IN A CORAOSI.VE AREA
ED
C. DATE OF LAST INTERNAL INSPECTION
Unknown
2. NOW WET SYSTEM PRE INSPECTION PROCEDURE
YES N/A
NO
A. PIPING FILLED WITH WATER PRIOR TO FLU SHING
B. FILLED BY TRIP TEST
27
C. AMOUNT OF DEBRIS COLLECTED AT TIME OF TRIP TEST:
None
D. SYSTEM REMAINED WET FOR PRIOR TO FLUSHING
3. RESULTS OF INITIAL EXAMINATION
A. TOTAL NUMBER OF CROSS MAINS EXAMINED
OF TOTAL CROSS MAINS
S- TOTAL NUMBER OF BRANCH LINES EXAMINED
OF TOTAL BRANCH LINES
C. TOTAL FOOTAGE OF BULK MAINS EXAMINED
OF TOTAL 13ULK MAINS
D. OTHER AREAS OF SYSTEM INSPECTED
E, INTERNAL CONDITION OF DRY PIPE VALVE
Very Clean
4. DESCRIPTION OF EXAMINATION
Removed cap at end of main very clean
Flemoved Sprinkler Head on Branchline All clean in6ide
S. ADDITIONAL CLEANING
A. IS THE SYSTEM REQUIRED TO HAVE Ar)orriONAL CLEANING
No
B, RECOMMENDED FORM OF CLEANING
N/A
C, REASON FOR ADDITIONAL CLEANING
N/A
This is to earfifled that the DRY SYSfE�M�
has been properly inspected for obstructions and internal
condition of the piping using tho standards set forth by N.F.P,A. # 25
Name of Inspector: Steve E111sor
Signature:
01/20/2012 13:15 2538727277 ARCHER PAGE 07/07
ARCHE . RA,*
CONSTRUCTION, I MC
IF- 7855 S, 206th STREET KENT WA. 98032 - 253-872-7222 - FAX 253-672-7277 - ARCHEI*219DR
FIRE DEPARTMENT CONNECTION INSPECTION REPORT
PROPERTY NAME: TJ MAXX #0852 DATE: 1/17/2012
ADDRESS: 23632 Highway 99, Ste 1200 AHJ: Edm,,,)nds
CiTY: Edmonds STATE: WA ZIP: 98026
Location of F.D.0 CK is on riser, FDC located Back of store by Risers
I.GENERAL CONDITIONS YES N/—All NO
A. IS THE F.D.0 LOCATION PLAINLY VISIBLE Ld
B. IS THE F.D.0 EASILY ACCESSIBLE Ll
C. IS THE F.D.0 CLEARLY LABELED
D, IS THE F.D.0 PIPING FREE OF PHYSICAL DAMAGE
E. IS F.D.0 PIPING FREE OF CORROSION
2. CHECK VALVES i
A. ARE ALL CHECK VALVES IN PROPER ORIENTATION
B. ARE ALL CHECK VALVES FREE OF LEAKS AND CORROSION
C, ARE CHECK VALVES IN GOOD CONDITION
3. BALL DRIP VALVES
A. ARE ALL CHECK VALVES IN PROPER ORIENTATION
B. ARE BALL DRIP VALVES IN GOOD CONDITION
4. CONNECTIONS
A. IS F.D.0 STORTZ TYPE
B. IS F.D.0 SINGLE CLAPPER DOUBLE CLAPPER x
C. CLAPPERS SWING FREE WITH NO BINDING
D. CAPS OR PLUGS INSTALLED ON F.D.0
E. ARE F.D.0 SWIVEL ROTATION NONBINDING Ld 10 Li
S. HYDROSTATIC TESTING
A. ALL F.D.0 PIPING HYDROSTATICALLY TESTED @ 200p&I FOR 2 hrs.
B. ALL VISIBLE JOINTS FREE OF LEAKS
C. PRESSURE MAINTAINED FOR TWO HOURS Ll Ld
D. HYDROSTATIC TEST ACCEPTABLE Ll t.�j Li
6. rLUSHING i
A. ALL F.D.0 PIPING FLUSHED DOWN STREAM OF CHECK VALVE. Li
B. AMOUNT OF SCALE COLLECTED FROM A SCALE OF 0 TO 5
C. AMOUNT OF DEBRIS COLLECTED FROM A SCALE OF 0 TO 5
D. FLUSHING RESULTS ACCEPTABLE
COMMENTS .1
Short run of pipe to FDC removed go ell to exaMine inside oi pipe all clean, operated check valve OK
Replaced FDC caps
Name of InSpector: Steve Ellisor
Signatuve:
Date: 11117�2012
SERVICE WORK ORDER
Aurora market Place
=2 ' S 1200
H �'79"865'0
ds
Site Contact: Manager on duty
Site Phone: 425-774-sool
-LLC
1860 BOY Scout Or
Fort Myers, FIL 33907
DisPedcher Benlia Gdffln
Place Store Stamp Here Pkase:
AcwU
nt NO.: 0209M00852
Work Order: 23502
P No.:
Affjri�ot� No.: WAo2sA
Service: Abyn Service
Fax
Date Completed:
/0 1 1( -
Print Technician's Name:
iCustomer fg tu Req"VI
x /
_zlkt�
CUStomer acknowL-dges reCelpt of service performed
Page: I
1-4SPF)CT10N.TEMTN0, AND KMWENANCE 72-101
INSPECTION AND TESTING FORM
SWWICE ORGANIZATION
Name, C-�-Ucr.'n
Addmams: 4 J
�1- �7�,
Wov -61 kie- 4 - 7
Representative; -aT- �' X.� Z
-, L-, 57,
ucense uo... 19*911*6 —5r—Ps'g>'o-!f
Telephone:
MONM)MG ENT17Y
Co. - L/-" '. -
TYPETRANSMISSION
0 Nicculloh
V lifuldplax
Q Digital
0 Reverse Nority
Q RF
0 Other (Specify)
DATE: to - 1( - ;,I,,
TIME: 7,c9c;, &A�?
PROPERTY NAME (USER)
Name: -T--k 6k,-x
Addres&*-2.3 kXX kAlc,% llk5 -,cA- j-ixo
Owner Contact 1-(�v t5,- i9c.4--
Telophne: Wx- /-�7-41
APPIROVING AGENCY
Contact: - d-S
Telephone:
SERVICE
a Weeidy
0 Monthly
* Quarterly
* Semiannually
fik"noally
0 Other (Specify)
Control Unit Manufacturer: Model No.:--Q
Circuit styles: I - ct"-<
Number of Circuits: I
&ft.am Rev.; �-j Ik
Last Date Systein Had Any Service Performed:
Lost Data that ArW,%ftware or Configuration Was Reviss&-
ALARWINITIATING DEVICES AND CIRCUIT INFORMATION
Quantity Circuit Style
hImnual. Km Alarm Boxes
Ion Detectors
Photo Detactors
Duct Detectors
HastDetectors
Pel hLe-
Waterflow Switches
Supervisory Switches
Other (Spechy):
Alarm veriftation feature is diaabled - enabled
F[CURE10.6.24 Example of an inspection and Testing Form,
(NFPA ftWP00fi*n and TOAU119, 1014)
200? FC.60on
S (JA- IT Iroa
72-102 NA7nONAL FlPE ALARm CODE
ALARM NOTIFICATION APPLIANCM AND CIRCUIT INFORMATION
Quantity cirviait style
Bells
Homo
Chimes
Strobes
Speakers
No. of slam notification appliance circuits: Other (Specify); boo -
Are circuito monitored for integritp. 0 Yes 0 No
SUPERVISORY SIGNAL-INMA71NG DEVICES AND CIRCUIT INFORMATION
Quaritity, Cirituit style
Building Temp.
Site Water Temp.
Site Water Lavel
Fho Pump Pbwer
Fire Pump Running
Pire Pump Auto Position
Fire Pump - Pump Contmier Trouble
Ftre Pump Riann%g
Generator Ila Auto Positioa
Generator or Controller Trouble
SWU6 Trawler
Generator Engine R%mnlug
Other.
SIGNAUNG LINE CIRCUITS
QWtItY and 001i Ovignaling firift circuits connected to system (mNPPA 72, Table 6.6. 1).
Quantity
Style(s)
SYSTEM POWER SUPPUES
(a) Primary (K&inY Nominal Voltage Kep Anips
Overatrrent Protection: Type
Amps
Location (of Primary Supply Panelboard):
(b) Secondary (Stwidbyk
UCUlAt0d CAPRElty to
Location of fuel starep-
TYPE BATMRY
0 Dry Call
/19, Nickel -Cadmium
* Sealed Load -Acid
* Uad-Acid
a Other (Spft*�.
Storage Battezy. Amp-14r. Rating V - 7
system, in hours; 24 60
FIL — Enffiu-Wv-n generator dedicated to fire aiartu system:
(a) Zvlat�q or standby Wtem, used so a bacWp to PrimM powar RupplY, IneWPA of using a secondary power supply:
9,416-- Einergericy system described in NFPA ?0, Article 100
legally required stanidby described In NFPA 70, Articie 701
Optional standb!y syfftarn described in MMA 70, Article 702, which also weau tim per*maAoe
v"Wraments ofArtide 700 or 701.
(NFPA fropectm amd TeAhg, 2 0941
FIGURE I0.6.L8 Coat��
2002 Edhion
JNSPEC)ION, 17-MNG, ANDRAWENANCL 72-105
PRIOR TO ANY TES11NO
NOTIFICATIONS ARE MADE
yes
No
Who
Monitoring Entity
Building
C3
Time
7,10
Occupants
Building Management
U
8:1
0ow (specify)
AHJ Notifted ofAny Impairments
SYSTEM TESTS AND INSPECTIONS
TYPE
visual
Functional
Ckintrol Unit
Interlsice Equipment
LempwLEDS
Puma
U
Prinwy Power Supply
Trouble Signals
Discormett. Switches
Ground -Fault Mohitorial
U
GKONDARY POWER
TYPE
Visual
Functional
conuuenta
Bactary Condition
9C
Load Valtage
Discharge Test
Charger Test
Specific Gravity
TRANSIENTSUPPAWSORS
REMOTE ANNUNCIATORS
NOTWMTION APPUANCES
Audibto
WC
r-
vunble
W,
-1-015 -
Speakers
Voice Clarity
INITIATING AND SUPEOVISORY DEVICE MM AND
INSPECTIONS
Device
LAW- & WN Type
'Woual Funartionjol
Check Tt"
FA-t-7
setting
Measured
80#lng
plass
FAD
a 0
a
U
U a
a
0
CI
-
Q
U
0
0
Comments:
FIGURE 10.61.3 Continued
(4FPA Impeoun and TW4,3 Of 4)
20M Ednion
72-104 NA37ONAL FIRE AI�Anf Corm
EMEAGENCV COMMUNICATIONS EQUIPMENT
Visual
Functional
Phone set
Phone Jacks
0
U ------
Off-Hook indicator
U -------
A-plifiev(9)
0 -------
Tone Generstor(s)
0
-------
Call-in Signal
0
---------
Systm Parfarmanas
0
3 --------
INTERFACE EQUIPMENT
Visual
DeWce
OpernUou
simulated
opwation
(specify)
0
(specify)
0
(Spec*)
SPECIAL HAZARD SYSTEMS
(Specify)
(Specify)
C1
(Specify)
:3
Special Procedures:
Com"Ienta.
SUPERVISING STATION MONITORING
yes
NO
TIVW Comments
Alarm Signal
Asil t,
Alam Restoration
A
Trouble Signal
3
—A — -, - r-
8upervism Signal
3
..--
ZAM � I : i
Supervisory Restoration
NOTIFICA11ONS THAT TESTING IS COMPLETE
yes
Who Time
Building Management
ta
Monitoring Agemy
tr—
Building Occupants
W,
fter (Specify)
a
W
The following did not opemte, correctly: iytk ---
BYstefn restored to normal operation: D&t.:
.4.0 Ti..
THtS TESTtNO WAS PERFORMED IN ACCORDANCE WITH APPUOAj3LE WpA STAMDARM
Name of Ins —5--le Arm= la:ir.-- Date:_1 Ti. '10,0
SignAtMe:
Name otOwner or Representative:
Date: -L P
Signature:
(NFPA InIppa6m arfd Tesling, 4 014)
FICURE 10.6.2.3 Co#Nmted
9M SORkin
— ---------- ----- --- ---
CITY OF EDMONDS
121 5TH AVENUE N. . EDMONDS, WASHINGTON 98020 (425) 771-0215
j
FIRE DEPARTMENT
LOCATION: 23632 Highway 99
BUSINESS NAME: T J Max #852
MAILING 23632 Hwy 99 #T
T
PHONE:
e.4 P
FIRE PREVENTION
SAFETY SURVEY
ADDRESS: Edmonds 98026
BUSINESS OWNER: The TJX CO-, Inc HOMEPHONE: 5083903517
EMERGENCY-1: Furlong, Tom HOME PHONE: 2069997646
KEY ACCESS-2: Choi, Anita HOMEPHONE: 4257745001
FREQUENCY
STATION& SHIFT
365
20 C
SCHEDULED
1,
09/01110
DATE DUE
UFIR o� 583
9006
ACTIVE
PERSON CONTACTED: 3:<'v A&/Ci14> INITIAL INSPECTION DATE
NAME OF INSPECTOR: ZVA,0'W,'1 Ala6_� �11.1;1197
FIRE AS 10,108 FA12/07 I'D LkBx FE I
SYSTEMS: ANNUAL
HAZARDS OUND AND LOCATIONS / COMMUNICATIONS
ENTER CODE ONLY ONCE 1�
VIOLATION CODE
-27 144: 1,44e& 7 4
L6vVIV4-4r, 121V Otr
2
_e 14,4�
3
4 ".A
4
5
5
6
6
7
7
UA
8
8
ist RE- PECTION
DATE DU�
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTED TO:
FINAL RE-INSPECT16N
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:
4
2
6
2
6
DATE:
CODE
SECTION:
5
3
7
7
RETURN RECEIPT
RECEIVED
6
4
8
1
8
DATE:
DISPOSITION:
7
8
\,,UETTER NEEDED [] YES NO
LETTER NEEDED ] YES NO
FIRE DEPARTMENT COPY
SecurityLink-
March 21, 2001
Pe*'�
u'o
110 A"& 5
'2
,;#'—d
Edmonds Fire Department
250 Fifth Ave. North
Edmonds, WA 98020
Re: Termination of Services
3033 16th Avenue West
Seattle, Washington 98119
(206) 443-9620
(206) 443-9205 Fax
n
Lj [MAR 2 ?, 2 0 0 11�
EDMONDS FIRE DEPT.
T ('
We are notifying your department that as of the date below, we are no longer
monitoring the fire alarm system listed below.
Name: Long's Drug
Location: 23632 Highway 99 — Edmonds, WA 98026 1 -7 9�� -&' " 0
C L-6 e'4-0
Date of Cancellation: 3/30/2001
Should you have any questions concerning this cancellation, please call our
office at (206) 443-9620.
Sincerely,
Peggy Anderson