417 3RD AVE SServing Brier, Lamurids, and
Mozintlake Terrace
SNOHOMISBI CO
10TY2
AN-7 A KWMAAL. www.FireDistrictl.org
417 3 rd Avenue S 98020
LOCATION:
Sound View Apts,
BUSINESS NAME:
7,,
'FIRE PREVENTION
12425 Meridian Ave S
INSPECTION REPORT
Everett, WA 98208
OEDMONDS
0 BRIER
Phone (425) 551-1200
0 MOUNTLAKE TERRACE
[I UNINCORPORATED
Fax (425) 551-1272
PHONE:
4257763851
" FAhWMY STATI�_� SH IF'*"
SCHEDULED My 20 1 1
DATE DUE 11`
-128 152
MAILING 417 3rd Avenue S, Edmonds, WA 98020 UFIR II,
ADDRESS:
Renee Schumacher
BUSAESS OWNER: HOME PHONE:
Olympic & Soundview LLC 4252908499
KE��E�i§ * HOME PHONE: ;RRENT YES NO
EMERGENCY-11 HOME PHONE: 17
BUSINESS ry 1 F
LICENSE 41—\j
INITIAL INSPECTION DATE
PERSON CONTACTED: vN 0 L,%
NAME OF INSPECTOR: '5+e� v6ei J-N 4-41
AS 1 Of 15 FA 1 Ot 15 RE 10115 - q 8 R R R R P I
11 1_.
Date Last Servi ced:
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
0
2
f—D
3
4 0-41 1 I'tA r!D'1v;D
5
6
7
3.
4
5
6
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'
2
INSPECTOR-
INSPECTOR:
INSPECTOR:
DATE:
DATE-
DATE: 3
VIOLATIONS
VIOLATIONS
CITATION ISSUED
PRE -CITATION
1 .5
1
LETTER SENT NUMBER 4
CODE 5
2 6
2 6
DATE SECTION
RETURN RECEIPT
7
3
RECEIVED 6
DISPOSITION
8
4 8
DATE
LETTERNEEDED [3 YES NO
LETTER NEEDED YES NO
8
Serving Brier, Edin 6 W&,a_hd 12425 Meridian Ave S
Mountlake Terrace Everett, WA 98208
Phone (425) 551-1200
www.FireDistrictl.org Fax (425) 551-1272
LOCATION:
417 3 rd Avenue S 98020
BUSINESS NAME:
Sound View Apts
MAILING
ADDRESS:
PHONE:
4257763851
FIRE PREVENTION
INSPECTION REPORT
76EDMONDS
0 BRIER
0 MOUNTLAKE TERRACE
[I UNINCORPORATED
FREQUENCY STATION & SHIFT
SCHEDULED
DATE DUE II'
UFIR 0
k, 428152
4 1 f a Avenue a, Edmonds, VVA 98020
BUSINESS OWNER: HOME PHONE:
EMERGENCY-1: Rr tJ.t�_ CAII—AC �,-q P, HOME PHONE: CURRENT
KEY ACCESS-2: Olympic & Soundview LLC. HOME PHONE: 4252908499 CITY YES NO
EMAIL: BUSINESS F�
LICENSE
PERSON CONTACTED: ke 'j t4 z .11 INITIAL INSPECTION DATE
NAME OF INSPECTOR: V— C' O'� C
/11D/15' 11011,5
FIRE SYSTEMS:. AS 10/14 FA 10/14 FE 10/14 FD Lk Box SP 7/09
MabAftimitc5smedOCATIONS COMMUNICATIONS
2
2
3
4F
4
4
5.
6
6
7
7-
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1 st RE -INSPECTION
DATE DUE:
2nd RE -INS PECTION
DATE DUE:
EXTENSION
GRANTEDTO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
DATE:
PERSON
CONTACTED:
... ........
INSPECTOR:—
PERSON
CONTACTED:
INSPECTOR:
DATE:
3
4
DATE:
VIOLATIONS
1' 5
VIOLATIOW..
5
PRE -CITATION
LETTER SENT
6CITA�TIONII UE
NUMBER:
2
6
2
6
DATE:
CODE
SECTION:
2_
7
2
RETURN RECEIPT
RECEI �D
-5-SRO-SITZIN
6
4
8
4
8
DATE:
-- -----
LETTER NEEDED YES NO
r LETTERNEEDED YES NO
FIRE PREVENTION
SNORCIMIST-4 CO. Serving Brier Ednionds, and 12425 Meridian Ave S INSPECTION REPORT
OEDMONDS
Mountlake Terrace Everett, WA 98208 OBRIER
FIRE Phone (425) 551-1200 0 MOUNTLAKE TERRACE
.DISTR T ww'wFireDistrictl.org Fax (425) 551-1272 0 UNINCORPORATED
e FREQUENCY I STATION & SHIF""S
I LOCATION: 417 3 rd Avenue S 98020 Annual 17-A
Sound View Apts 4257763851 SCHEDULEDMay 2015
BUSINESS NAME: PHONE: DATE DUE 0
0428 152
MAIUNG 417 3rd Avenue S, Edmonds, WA 98020 LIFIR
ADDRESS:
BUSINESS OWNER: HOME PHONE:
Olympic & Soundview LLC 4252908499
EMERGENCY-1: HOME PHONE: CURRENT
KEY ACCESS-2: HOME PHONE: CITY YES NO
BUSINESS
EMAIL: LICENSE FJ El
PERSON CONTACTED: INITIAL INSPECTION DATE
NAME OF INSPECTOR.,V. t 01�'Vr
6ILIVIb: AS9/13FAX FE10/13(FDLkBoASP-7-/09,
I
IdIlf /0N42 10144
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
1AI 142-
1
2
2
3
3
4
4
5
5
6
6
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:
EXTENSION
GRANTEDTO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
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
18
4
18
DATE:
DISPOSITION:
7
LETTER NEEDED E] YES El NO
LETTER NEEDED [] YES NO
8
FIRE DEPARTMENT COPY
Serving Btilei . _. Ediiiond's,'di
SNOHOMIS 1�1 mountla Terrace
'FIR
Twww.FireDistrictl.org
LOCATION: 417 3 rd Avenue S 98020
BUSINESS NAME: Sound ViewApts
MAILING
ADDRESS: 417 3rd A.venue S, Edmonds, WA 1.18020
id 12425 Meridian Ave S
Everett, WA 98208
Phone(425) 551-1200
Fax (425) 551-1272
PHONE: 4257763851
BUSINESS OWNER: HOME PHONE:
EMERGENCY-1: Olympic & Soundview LLO HOME PHONE: 4252908499
KEY ACCESS-2: HOME PHONE:
EMAIL:
PERSON CONTACTED:
NAME OF INSPECTOR:
F I R E SYST EM S: AS 91 -1 Q FAv�rl'l 3 FE 10 /1
??'FD Lkeo�tp -110/07',"_
r\01
FIRE PREVENTION
INSPECTION REPORT
YDMONDS
BRIER
0 MOUNTLAKE TERRACE
[I UNINCORPORATED
FREQUENCY STATION & SHIFT
A.nnual I T-D
SCHEDULED
DATE DUE I, Mav,,1014
UFIR 0 .428 152
CURRENT
CITY YES NO
BUSINESS
LICENSER -t-El
INITIAL rSPECTION DATE
-I i 1 '00 1 1 L-1
V
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
2
2
,3-
3
4 A
4
5
4L)
6
6
7
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
Ist RE -INSPECTION
2nd RE -INSPECTION
EXTENSIO N
FINAL RE -INSPECTION
VIOLATIONS
DATE DUE:
DATE DUE:
GRANTED TO:
DATE DUE:
CITED:
PERSON
PERSON
PERSON
CONTACTED:
CONTACTED:
CONTACTED:
1
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
VIOLATIONS
PRE -CITATION
CITATION ISSUED
5
1 5
LETTER SENT
NUMBER:
4
CODE
5
2
6
2
6
DATE:
SECTION:
RETURN RECEIPT
6
3
7
3
7
RECEIVED
DISPOSITION:
4
18
4
18
DATE:
7
�l LETTER NEEDED E] YES El NO
LETTER NEEDED [] YES El NO
8
FIRE DEPARTMENT COPY
Emerald Tire
Fire spfinkler Specialists
11021 Cramer Rd. KPN - Gig Harbor, WA 98329
Office (253) 857-2056 - Fax (253) 857-2312 - Local 699 Contractor
AUTOMATIC SPRINKLER SYSTEMS
(0nP lqvctpm npr Rpnnrt)
,�;_/ I _Sa
,V/-7 3LSr .4ve. -,, -
Occupancy Address: (4& 936�
Occupancy Name-Sovy
Responsible Person:
Building Owner:
Phorve Number:
Phone Number:
Date of Inspection: Type of Inspection: Quarterly n
Testers Name (Please Print): Q=m�j WA State FSCC#
I U I I
Annual Ej�" Other E]
0633-IT-0518
DRY SYSTEM/PRE-ACTION SYSTEM:
1. Trip test (dry trip or ful.1 flow) co ucted: ...................................... I ............ Yes F-I No
System tripped in se onds.
2. All flow switches, supervisory s itches and alar ells tested., ..................... Yes E] No N/A r-1
3. Alarm bell operates: ... .... ... ................... ...................
......................... Yes No Fj N/A
4. Flow tests conducted ........................ .................
................................. Yes No E]
Flow pressure: psi 2-i ch ain7 ....................................... Yes Fj No
d alar ells b
.... ..............
0
. ....................
'c
5. Systems inspected and /lubricated .......... . .. ........................................... Yes Non N/A n
"r'
6. Air compressor refills system' 30minu s: .. .......................................... Yes No F�
I r L,
7. System drained and rest ed to normal operation: ..................................... Yes E] No E)
8. Were the heat actuation devices tested on pre -action and deluge system? ..... Yes E] No[-] N/A[:]
WET SYSTEMIANTI-FREEZE SYSTEM: Tested at
1. Trip test conducted: .............................................................................. Yes No r-1
Static pressure: //S psi Flow pressure: 2-6 psi 2 inch drain? ....... Yes No E] N/A E]
2. Flow switches, supervisory switches and alarm bells tested: ..................... Yes&( No F-1 N/A [I
3. Alarm bell operates: ............................................................................. Yes Id No r-1 N/A E]
4. Systems inspected and lubricated: .......................................................... Yes 011/'No F-1
5. Pressure regulating valves tested: ........................................................... Yes E] No F� N/A R/
AUTOMATIC SPRINKLER SYSTEMS (continued)
General:
1. Central Station Monitoring? .......................................................................... Yes W' Non
Monitoring company name
2. Location of Sprinklers
100% ......... 5a" Parking, ........ Basement ......... n Hallways ......... Other .........
3. Pumper connections and clapper valves unobstructed ............................... ....... Yes Eo( Non
4. Sprinkler heads less than 50 years old ............................................................. Yesy Non
5. Sprinkler coverage is acceptable ..................................................................... Yes [;j( No F-1
6. Spare sprinkler heads are available ................................................................... Yes E�( No F1
7. Systems left in service .................................................................................... Yes'[e No F�
8. Valves are sealed or supervised ...................................................................... Yesy Non
'9. Signs are provided on valves ................ I ........................................................ Yesw NoR
10. City static water pressure 1 /,3 . -psi.
Problems Found:
/' 0"j, -,. o
.6z= Lle
Corrections Made: Date Corrected: Corrected By: ft5z
SIGNATURE OF TESTER:
AGENCY- Emerald Fire PHONE: 253-857-2056
MAILINGADDRESS: 11021 Cramer Road KPN. Gig Harbor, WA 98329
Emerald Tire
Fire Spfinkler Specialists
AUTOMATIC , SPRINKLER SYSTEMS
(One System per Report)
- Z�3 1
411-7 �3 Lc(2 4�e. S.
Occupancy Address:- "c, 2EQZQ Occupancy NZIM8,%"jeAj_�
Responsible Person: Phone Number:
Building Owner:
Phone Number:
Date ofinspoctlon:jo-io-11 Type of Inspection: Quarterly 0 Annual 9�cceptance DOther o
Fire Sprinkler Certificat0633-It-051809
Testers Name (Please Print):_ZL * ?0,oaw
. (I I of Competency FSCC #
DRY SYSTEM:
1. Trip test (dry trip) conducted ............................................... I ..................... Yes D No 0
System tripped in seconds.
2. All flow switches, supervisory switches and alarm bells teste�d. /. .................... Yes..0 No 0 N/A 0
3. Alarm bell operates: ............... /-A ......................... I * *, * .................... Yes 0- No -0 NIA 0
.4. Flow tests conducted: ............ ..... : � * .... * """" *** ..... * * Yes 0 No 0
Flow pressure: 2-in dra" ? ... ........................................ Yes El No 0
in
5. Systems inspected and lubillcated: ...... ... ... ....................... ........... Yes 0- No 0
0
6. Air compressor refills system in 30 utes: ........ ....................................... Yes D No 0
rM peration:
7. System drained ind restored It ormal operation ....................................... Yes 0 No D
8. Were the heat actuatio, Ices tested on pre -action and deluge system? ....... Yes 0 No 0
WET SYSTE.M.-
I - Flow test conducted: ............................................................................. Yes E(No 0
Static pressure: /jo si Flow pressure: si 2-inch drain? .............. Yes VNo 0 Other 0
2. Flow' switches, supervisory switches and alarm bells tested: ... I ...................... Yes [I/No 0 N/A 0
3. Ala'rm bell operates: ................... I ...................... 11 ........................... Yes Q/No 0 N/A 17
4. Systems inspected and lubricated: ........................................................... Yes VeNo 13
5. Pressure regulating valves tested: .......................................................... Yes 0 No 0 /v,/.A V1
H 02 1 Cr3nicr Rd. 11"M -- Gia Harbor, WA Q8329 - Officc (2-53) 85 -1-_'0*-_6 - F-ax (21:--,31, 857-2312 , Local 699 Contractor
-ER SYSTEMS-Lgontinued)
9.eneral:
1. Central station monitoring? ...................................
................. : ........ n
yes, 0 No L
Z
Monitoring Company pame .5=
2. Location Of Sprinklers
100% ...... Parking .......... [3 Basement ........ 0 Hallways ........ o Other ......... ci
3. Pumper connections and clapper valves unobstructed ................................ Y*es &/No 0
.4. Sprinkler heads lessi'than 60 years old .................................................... Yes IV No 0
5. Sprinkler coverage is 'acceptable ................ ............................. Y( S
VN 0 0
6. Spare sprinkler heads are available ................
...........
............................... Yes It No 0
7. Systems left in ser . vice ........................................................... Yes tl/No 0.
8. Valves are sealed or supervised ................................................
.................. s
9. Signs are provided on valves ..............................
............. Yes No 0
10. bity static water pressure 1) p psi.
Probrems Found
/:&S- COVC-164
Corrections Made: Date Corrected: C . orrected By:*
SIGNATURE OF TESTER
TLVd M4
AGENC P H 0 N E,,-7,T-3 �QDY6,
MAILING ADDRESS:J/0;1/ WA91Y kiPlAJ 11W1,,v / iiia OD -io
CTP-4
11/02/2012 16:41 253B572312 EMERALD FIRE LLC PAGE 01/04
PEmerald Tire
. Mre Spfinkder Specialists
11021 Cramer Rd. KPN - Gig HarborWA 98329
Office (253) 857-2056 - Fax (253) 857-2312 - Local 699 Contractor
AUTOMATIC SPRINKLER SYSTEMS
(Ohe System per Report)
4r/ -7 3 f-W 4ve - _T
Occ ipancy Address: 1,nin, __qjb= Occupancy NameSam_A(t
Resl onsible Person: Phone Number:
Buil, ling Owner; Phone Number:
Datq of Inspection: io -1$:-j 2b� Type of Inspection: Quarterly Cj Annual R( Other
Test !rs Name (Please Print): Wch __4 — WA State FSCC# 0633-IT-05180
V I,
PM 5Y5TEM/PBE-ACTIQN SYSTEM:
1 rrip test (dry trip or full flow) co ucted: .................................................. Yes [I No 0
System tripped in_se nds.
t, Z-,*"
2. 411 flow switches, sup tches and ala m lis tested: ..................... Yeso No[] WAD
3. klarm bell operates:.7. Ivy S .. i ...... 1*11,11*11,111*11, ........................ YesE] No[j N/AE]
4. 9ow tests conducted .......................... ................................................. Yes El No El
�*i ... clral
-low pressure: psi 2-i dral . ...................................... Yes Ej No Ej
ubric'ated .............. .
0 m
5. Systems inspected and lubricated ............... . ... .................................... Yes E] No E] N/A 0
6. Mr compressor refills system' 30minutes: . ............................................ Yes 0 No D
op a No E]
7. ;ystem drained and rest ed to normal operation: ..................................... Yes [_
S. Nere the heat actupKan devices tested on pre -action and deluge system?..... Yes [3 No[] N/AE]
ME MTEWANMEBEEZE SYSUTIEMMJested at �
Irrip test conducted: ............................................................................ .... Yes [j� No F-1
;taticpressure: thr psi Flow pressure: 0110 psi 2 inch drain? ....... Yes No[] N/A
2. --low switches, supervisory switches and alarm bells tested: ..................... Yes No El N/A
3. klarm bell operates: .......................................................... a .................. Yes No Fj N/A r7
4, ;ystems inspected and lubricated: .......................................................... YesEKNoCl
5. 5ressure regulating valves tested: ........................................................... YesE] Noo N/A IT/
11/02/2012 16:41 2538572312 EMERALD FIRE LLC PAGE 02/04
AIMMATIC SPRINKLER SYSTEMS Lcontinued)
Ge ieral:
1.
Central Station Monitoring? ..........................................................................
Yes [�/ No
Monitoring company name
2.
Location of Sprinklers
100% ......... E� Parking .......... Basement ......... C] Hallways ......... 0 Other ........
3.
Pumper connections and clapper valves unobstructed .......................................
Yes
No
4.
Sprinkler heads less than 50 years old ..............................................................
Yes
No
5.
Sprinkler coverage is acceptable ....................................................................
Yes EZ
No F-1
6.
Spare sprinkler heads are available .................................................................
Yes
NoM
7.
Systems left in service ..................................................................................
�es
No C]
8.
Valves are sealed or supervised ......................................................................
Yes C2'
No F71
9.
Signs are provided on valves .........................................................................
Yes
No F-71
10.
City static water pressure psi.
Pro
jjMs Eo_un—d:
Cqrj
!ptions Made: Date Corrected; Corrected By:
SIGI ATUREOFTESTER:
AGE JCY.- EmgzL4d-Fim- PHONE- Z53L857-2056
MAI JNG ADDRESS: —1-1-OZI Cramer Road
Emerald Pire
Fire Sprinkler 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: 11,7 _51�&Je-
Occupancy Nan
Responsible Person: 9� om - Phone Number:
Building Owner: Phone Number:
Date of Inspecti on:
z��e Type of Inspection; Quarterly E] Annualj��- Other E]
Testers Name (Please Print): WA State FSCC# JZ�
DRY SYSTEM/PRE-ACTION SYSTEM:
1. Trip test (dry trip or full flow) conducted: .................................................... Yes E] No E]
System tripped in seconds.
2. All flow switches, �uperv'isory`switches�a'ncl alarm bells -te"st e-d: ......................... Yes E] No E] N/A E]
3. Alarm bell operates: .............................................................................. Yes E] No Ej N/A 0
4. Flow tests conducted: ........................................................................... Yes E] No F�
Flow pressure: psi 2-inch drain? ....................................... Yes E] No Ej
5. Systems inspected and lubricated: .......................................................... Yes E] No E] N/A F�
6. Air compressor refills system in 30 minutes: .............................................. Yes E] No F-1
7. System drained and restored to normal operation: ..................................... Yes E] No Ej
8.
Were the heat actuation devices tested on pre -action and deluge system? ......
Yes E] No [-]
N/A E]
<4T
=SYsTaANTI-FREEZE SYSTEM: Tested at
Trip test conducted: .................................................................................
Yes;�`No El
Static pressure: psi Flow pressure: psi 2 inch drain? .......
Yes_0 NoE]
N/A[-]
2.
Flow switches, supervisory switches and alarm bells tested: .....................
Yesjo No E]
N/A E]
3.
Alarm bell operates: .............................................................................
Yesj?�' No E]
N/A E]
4.
Systems inspected and lubricated: ..........................................................
Yes [Z— No F]
5.
Pressure'regulating valves tested: ...........................................................
Yes[:] NoE]
N/AZZ
Y_
AUTOMATIC SPRINKLER SYSTEMS (continued)
General:
1 Central Station Monitoring? ........................................................................... YeSO_ No F1
Monitoring company name
2. Location of Sprinklers
100% ......... ;jR" Parking ......... El Basement ......... E] Hallways ......... E] Other ......... F]
3. Pumper connections and clapper valves unobstructed ....................................... Yesol No E]
4. Sprinkler heads less than 50 years old ......................... ! ................................... YesRF- No E]
5. Sprinkler coverage is acceptable .................... ................................................ Yes Gd--No E]
6. Spare sprinkler heads are available .................................................................. Yes [;�- No El
7. Systems left in service .................................................................................. Yes 2-- No El
8. Valves are sealed or supervised ...................................................................... Y6542�' No El
9. Signs are provided on valves ......................................................................... Yes,�4- No
10. City static water pressure —psi.
Problems Found:
'000�
Corrections Made: Date Corrected: Corrected By:
SIGNATURE OF TESTER:
AGENCY. Emerald Fire' C-or PHONE: 253-857-2056
MAILING ADDRESS: 11021 Cramer Road KPN, Gig Harbor, WA 98329
I Z )�ITV OF EDMONDS
1121 �T' AVENUE N. - EDMONDS, WASHINGTON 98020 (425) 771-0215
FIRE DEPARTMENT
t 89
LOCATION: 417 3rd Avenue S
BUSINESS NAME: Sound View Apts
MAILING 12625 4th Ave W #200
FIRE PREVENTION
SAFETY SURVEY
PHONE: 4257763851
ADDRESS: Everett 98204
BUSINESS OWNER: Olympic & Soundview LLC . HOMEPHONE: 4252908499
EMERGENCY-1: Wilson, Mindy HOME PHONE: 4252903499
KEY ACCESS-2: Depuy, Charlene HOMEPHONE: 4254220173
FREQUENCY
STATION& SHIFT
2
I
17 D
SCHEDULED
DATE DUE 1�
05/0-1/10
LIFIR 1� 423 5152
ACTIVE
PERSON CONTACTED: LA-"P+ L-.16-f r" 04-' V1,f-P, iL- A-06.f-C., INITIAL INSPECTION DATE
NAME OF INSPECTOR: �A 'j W7-c- P_ tj ?, % (0 Clf4eC(4- fl-1110
FIRE FA12/0rS12103jSP10/07rb Lkl3x FE 12 fp
_ j
SYSTEMS: JA 10 0 V— ANNUAL
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS ENTER CODE ONLY ONCE 1�
1 5-14;yj^ t.-f- 3rd f-f-.0'r-
VIOLATION CODE
x0
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2 A/Iou,,4 e_X-J�14!j�tf�tLkj,.-
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5
5
6
6
7
7
8
8
1st RE -INSPECTION
D�TE 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: C)
DATE:
DATE:
3
VIOL IONS
1 r5 C:`� 1
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
�i
.8
4
a
DATE:
DISPOSITION:
8
LETTER NEEDED [] YES NO
LETTER NEEDED 0 YES E] NO
1
FIRE DEPARTMENT COPY