23713 EDMONDS WAY2,371J EDMOti0f.04y
FIRE PREVENTION
Serving Brier, Edmonds, and'
12425 Meridian Ave S
INSPECTION REPORT
SNOIiOMISfl CO.
Mountlake Terrace\
Everett, WA 98208
S
D BRIER
T LUFF
Phone(425)551 -1200
0 MOUNTLAKE TERRACE
[3 UNINCORPORATED
jLpjL www.FireDistrictl.org
Fax (425) 551-1272
FREQUENCY
STATION & SHIFT
LOCATION: 23713 Edmonds Way 98020
2015
20-B
BUSINESS NAME: Orthodontics Exclusively
J
PHONE: 4257760124
SCHEDULED
DATE DUE � Nov 2015
MAILING
ADDRESS: 23713 Edmonds Way, Edmonds, WA 98020
UFIR o 593 55
BUSINESS OWNER:
Dr. Alowat-d ju(:
HOME PHONE:
EMERGENCY-1:, goa 7/ f
HOME PHONE:
'CURRENT
KEY ACCESS-2:
HOME PHONE: CX=
CITY YES NO
EMAIL:
BUSINESS
LICENSE
PERSON CONTACTED:
INITIAL INSPECTION DATE
NAME OF INSPECTOR: 1��q tA V2 xv
FIRE SYSTEMS: F E —SA-4- el
Date Last Serviced:
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
----
- - -
2
7'
3 . ...... . ....
3
4
4
5
5
6
6
7
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1 st RE -INSPECTION 2nd RE -INSPECTION EXTENSION FINALRE-INSPECTION VI I OLATIONS
T�TE DUE: GRANTED TO: DATE DUE: CITED:
PERSON PERSON PERSON*
CONTACTED: CONTACTED: CONTACTED:
INSPECTOR: INSPECTOR: INSPECTOR: 2
DATE: DATE: DATE: 3
_VF66�T-i6�-s7`
I PRE -CITATION
5. E IE�T. 4
CODE
-5
2 �6 2 6 DATE.
. ... . .... . ...... .. ....
RETURNRECEIPT 6
3 t7 3 17 RECEIVED-., 'j
7
4 —18 4
DISPOSITION:
LETTERNEEDED YES 0NO_ LETTER NEEDED YES 8
CITY OF EDMONDS
BUSINESS LICENSE APPLICA71ON — COMMERCIAL
FEE: $125.00
CITY CLERK'S OFFICE, BUSINESS UCENSE DIVISION
121 5TH AVENUE NORTH, EDMONDS, WA 9=0 PHONE 425.775.2525
•
Building
•
Engineering
•
Fire
•
Planning
0
Police
OFFICE USE ONLY
BL#
Customer #
100'3mloi
sic
W1,710
Year,;
Class
131
I SHD
I Data Paid SLTR#
u
1vt
ID
0 -M-ljt,�'bctl
Fee
I Jili
Mailed
Deleted
INSTRUCTIM: please complete Me application In full and attach the in -r Plan Wddle Initial or name required of all pardes concemed. If no
middle name, please indicate by wrtting NMN. Sign and return application with fee, Pleas advIso of any change In status. Now license required If
business changes location or ownership. Notification to City of Edmonds required N business closes. Ucense expires December 31&t each year. Renewal
must be submitted prior to January 31" to avoid late fees.
BUSINESS NAME Howard Jue, DDS, PLLC
BUSINESS ADDRESS 23713 Edmonds Way Edmonds, WA 98026
Sliest suite # City, State, Zipcodo,
MAILING AD 23632 Hwy 99 F267 Edmonds, WA 98026
Street or PO Box # Suits # City, State, Zip Code
BUSINESS PHONEJ-= -]F-T 0
713 11301-1703 WA STATE TAX ID # (UBI) 1 6 1 OT-3 5 0 1 6 8 1 3
BUSINESS E-MAIL orthohj@gmaii.com BUSINESS WEBB
BUSINESS OWNER I MAIN CONTAcr___�Hioward J Lie, DDS 1 713 1301-1703
Name Phone Number
1, 1
PROPERTYOWN Name Phone Number
EMERGENCY NOTIFICATION (For Premise Across In Emergency): 713 301-1703
Jue Howard I
Last Name First Name MI Phone Number
I I I
First
NATURE OF BUSINESS (Provide a Detailed Description of Business AcIlivities, Products &
SPACE ALTERATIONS TO BE MADE: YESNo--�
PREVIOUS BUSINESS AT THIS ADDRESS —
NUMBER OF EMPLOYEES 5
Dental Practice
La
SQUARE FOOTAGE OF BUAESS spAc,: 2.300
TYPE OF BUSINESS — PLEASE CHECK APPROPRIATE CATEGORY:
[3 CONSTRUCTION
• FINANCE. INSURANCE, REAL ESTATE
• LANDSCAPE. HORTICULTURAL
c3 MANUFACTURING
• NON-PROFIT
• RETAIL
0 SECONDHAND DEALER
gt SERVICES
o WHOLESALE
o OTHER
Phone Number
PROPOSED OPENING
BUSINESS HOURS: 8-5
DAYS OPEN:
oSUNDAY 9 WEDNESDAY
9 MONDAY Z THURSDAY
EfTUESDAY o FRIDAY
uSATURDAY
AMUSEMENT DEVICES� ON PREMISES? YES— NO—?�—IF YES, TOTAL NUMBE — LIQUOR SOLD ON PREMISES? YES_ NO---X—
GAMBLING? YES-- NOL- AX CIGARETTES SOLD ON PREMISES? YES-- NO---X—
FLAMMABLE OR HAZARDOUS MATERIALS USED OR STORED? YES_ NO�— IF YES. PLEASE PROVIDE A LIST OF MATERIALS AND QUANTITIES:
PARKING SPACES ON SITE: TOTAL SPACES---13— ACCESSIBLE SPACES FOR HANDICAP PARKING I
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? YES—.?�— NO —
Howard Jue DDS
TITLE Ownei ""--
SOLE PROPRIETORSHIP
NAME
LAST FIRST MIDDLE INITIAL
ADDRESS
STREET SUITE/APTIUNIT # CITYISTATE/ZIP CODE
HOME PHONE( DRIVERS LICENSE OR ID # & STATE
DATE OF BIRTH CIrflSTATE OF SIKH COUNTRY OF BIRTH
PARTNERSHIP - PARTNER I
NAME
LAST
FIRST
MIDDLE INITIAL
ADDRESS
STREET
SUITEfAPT/UNiT #
CITYISTATEOP CODE
HOME PHONE(
I
DRIVERS LICENSE OR ID # & STATE
DATE OF BIRTH
---jCITYISTATE OF BIRTH COU14TRY OF BIRTH
PARTNERSHIP - PARTNER 2
NAME
LAST
FIRST
MIDDLE INITIAL
ADDRESS
STREET
SUITE/APTfUNIT #
CITYISTATErZIP CODE
HOME PHONE(
I
RIVER'S LICENSE OR ID # & STATE
CORPORATION/ LLC or PLLC
NAME OFCORPORATION, Howard Jue DDS PLLC FEDERALTAXID# 47-4838512
CORP.ADDRESS 23632 Hwy 99 F267 Edmonds, WA 98026 ( 713 ) 301-1703
Street Suite, Apt. Unit # city, State and Zip Code Phone Number
CORPORATE OFFICERS:
Last Name First Name MI Title DateofBirth Driver's License or Other D# /State
Jue Howard T Member 09/28/1981 -SUE " H-T-MO 9
LOCALCONTACT
Last Name First Name MI Title DateofBirth
Driver's License or Other ID# /State Phone Number
CITY USE ONLY:
BUILDING DEPT.
APPROVE
DISAPPROVE
DATE
SIGNATURE
OCCUPANTLOAD
BUILDING PERMIT
OCCUPANCY GROUP
COMMENTS
ENGINEERING
APPROVE
DISAPPROVE
DATE
SIGNATURE
FIRE DEPT.
APPROVE
DISAPPROVE
DATE
SIGNATURE
I.I.F.I.R.
COMMENTS
PLANNING DEPT,
APPROVE
DISAPPROVE
DATE
SIGNATURE
ZONING CODE
CONDITIONAL USE PERMIT
COMMENTS
POLICE DEPT.
APPROVE
DISAPPROVE
DATE
SIGNATURE—
COMMENfS
i -
go
ce.
U4
d .N �a
, C36.
1
FIRE PREVENTION
Sokvifig' Brier' Edmonds, and
12425 Meridian Ave S
INSPECTION REPORT
SNOHOMISH CO.
-.1dountlake
FIRE
Tq�rrace 4
Everett, WA 98208
EDMONDS
9BRIER
S' R T
Phone (425) 551-1200
---0 MOUNTLAKE TERRACE
[I UNINCORPORATED
www.FireDistrictl.org\
Fax (425) 551-1272
FREQUENCY STATION 1, SHIFF11�
LOCATION: 23713 Edmatids Way Aw2f)
E.Nel. 20-A
I
BUSINESS,NAME:
EXLIU8i,,,,0IV
PHONE: 4257760124
SCHEDULE&,
DATEDUE av2014
MAILING UFIR,W
ADDRESS: 23713 Edmn& %Aiay:4EdrTK5ndti, %jVA 08020
4 BUSINESS OWNER: HOME PHONE:
EMERGENCY-1: HOME PHONE: "CURRENT
KEY ACCESS-2: HOME PHONE: CITY YES NO
BUSINESS
EMAIL: LICENSE IN] El
PERSON CONTACTED: -ty_j't�,41 LLL Oo-� D-tA INITIAL INSPECTION DATE
NAME OF INSPECTOR: I/' \%-It I I Vic / I r,
�-IRE sy.S IlEmis: FE 9 1 T A —
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
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
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
1
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DXfE:
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
8
DATE:
DISPOSITION:
LETTER NEEDED [:] YES No
LETTER NEEDED F] YES NO
8
FIRE DEPARTMENT COPY
- - - - - -
- - - -
FIRE PREVENTION
Set-ving Bilei; Edinonds
12425 Met-idian Ave S
INSPECTION REPORT
SNOHOMISH CO. I
and
F1 E
Evei-ett,* WA 98208
OEDMONDS
0 BRIER
M the Town o bodway
f W
DIST I
Phone (425) 551-1200
E]WOODWAY
0 MOUNTLAKE TERRACE
wwwFireDistrictl.org
Fax,(425) 551-1272
0 UNINCORPORATED
LOCATION: 23713 Edmonds Way
FREQUENCY STATION & SHIFT
731 20 6
BUSINESS NAME: Orthodontics Exclusively
PHONE: 4257760124
SCHEDULED
DATE DUE 1' 08/01/1.
MAILING 23713 Edmonds Wy
LIFIR � 593 8005-
ADDRESS: Edmonds
98020
BUSINESS OWNER: nBerglund, Penn)r
HOME PHONE: 4254889860
ACTIVE
ERGENCY1:
7�
H PHONE.
CURRENT -
KEY ACCESS-2: Cain, Beverly
HOME PHONE::--1Q&R4-fiM_
CITY YES NO
BUSINESS F] F
LICENSE
PERSON CONTACTED:
INITIAL INSPECTION DATE
NAME OF INSPECTOX�t
FIRE FA 11
FE rl
_:f_1 _Z10
" "
SYSTEMS:
A N VU kC
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
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
2nd RE -INSPECTION
FINAL RE -INSPECTION
EXTENSION
VIOLATIONS
DATE DUE,
DATE DUE:
GRANTED TO:
DATE DUE:
CITED:
PERSON
PERSON
PERSON
CONTACTED:
CONTACTED:
CONTACTED:
1
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
2ATE:
DATE:
3
VIOLATIONS
VIOLATIONS
PRE -CITATION
CITATION ISSUED
15
1 15
LETTER SENT
NUMBER:
4
CODE
5
2
6
2
6
DATE:
SECTION:
RETURN RECEIPT
3
7
3
7
RECEIVED
6
DISPOSITION:
4 18
4
8
DATE:
7
LETTER NEEDED [3 YES NO
LETTER NEEDED [] YES El NO
8
FIRE DEPARTMENT COPY
r0ft PMWfl0'U 080'
T-Mir
Address:
Occupied as:
Fire Alarm Inspection Report
ZT�fo DO,--;WC:.r
Gomo'-jer
Tester gorc.."( )&C-S-" Certification #: Y- 06eY9
Date: =�Mt�;O? 2CCA customerd: 01?9z6R cs#:
Type ofinspection: Monthly OQuarterly 0 Animala"Acceptance 0 Other 0
Fire Panel Communication Pond I Fire Panel Auxiliary Power Supply
Manufacturer. _ELEL7ALE-ar- Manufacturer Manufacturer:
Model: I 6c) Model: Model:
# ofinitisfing circuits: 5 # of initiating circuits: # of initiating circuits:
#ofsignWing circuits: # 017signaling circuits: # of'signaling circuits:
Battery Voltage: 3.3 volts Battery Voltage: volts Battery Voltage: volts
Charge Circuit Voltage: volts Charge Circuit Voltage: volts Charge Circuit Voltage: volts
Full Load Voltage: 13. k volts Full Load Voltage: volts Full Load Voltage: volts
I ) Trouble signal with AC power off. Yes gi./ No 0 NIA 0
2) System operates satisfactory on stand-by power. Yc%;a" No 11 N/A 0
3) All signals operate on AC power: Ye� P/ No 0 N/A a
4) trouble signals with no battery: Yes V No 0 N/A 0
5) Secondary phone line transmits primary phone line failure: Yes 0 N oO WAD/
6) STU communicates SCAN failure: Yes 0 No 0 N/ALg./
7) Alarm system meets audibility standards: Yes Q1 No 0 N/A 0
8) All circuits checked for electrical supervision: Yes J;,/ No 0 N/A 0
9) Panel checked per manufacturer instructions: Yes %P/ No 0 NIA 0
10) AD Auxiliary- equipment operates (Elevators, Fan, Dampers, cic ... Yes 0 No 0 N/AdG/
11) Central station or remote connection operates: Yes Lk" No 0 N/A 0
a) Nam ofmonitoring company-. Vlf�$TaC:nc)-a �e ALAe�
b) Automatic delay ofgcncral idarm: minutes None Installed 0
12) Key to panel available: Ycs&GK No 0 NIA 0
13) Operating instructions available: Yes P/ No 0 N/A 0
14) Test records at panel ---Yc%.1R/ NoG - -N/A 0
Type of equipment
# of units tested
Satisfactory
Unsatisfactory
N/A
# of units
Balls, Harris, Chimes
Voice'alarm speaken;
Vioual Alarm Devices
Trouble Indicators
��aperviscdl Switch= (automatic sprhWcrs)
Auto Sprinkler Flow Switches
Smoke D*ctor(s)
Heat Detector(s)
Manual Pull Stations
Ventilation Comrols Operate
Central St.fion
Anourciatins
Elevator Call Down
Fire Dampers / Smoki Dampers
phone JWAS
Automatic Door Unlocks (fatilside)
Autinnatio Door Rate=
Other
Other
Problems found:
If more space [a required, use a sepairs te sheet and attach
Corrections made: ism
Date Corrected: Cl— ';t By:
This is to certify that the Fire Alarm systain petty tea it and reliability to cover the items listed in this reporL is consistent with the fire
Wotan standarda. all corrections required lis an tio
Signature ofowner of representative
Signature of tester VO mrao� ocs's- Date
PROTECTION ONE ALARM SERVICES, INC
7617 South 1806 Sum
Kent WA 98032
(988) 849-6276
Lic # PROTEOA123N4