543 MAIN ST STE 104fill Iy, -7 AX r--
/1 Aj FIRE PREVENTION
Sei-ving Bi- y "INSPECTION REPORT
leip; is 12425 Met-idian Ave S
CO OEDMONDS
Mountlake Terraceand Everett, WA 98208
0 BRIER
MOUNTLAKE TERRACE
FIR the Town of Woodway Phone (425) 551-1200 El WOODWAY
DISTRrTwww.FireD&trictl.org Fax (425) 551-1272 0 UNINCORPORATED
FREQUENCY I STATION & SHIF"'I
LOCATION: 543 Main Street 104 731 17 D
BUSINESS NAME: Struck, Mary Ma PHONE: 4257718245 SCHEDULED
DATE DUE � 05/01/12
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MAILING 543 Main St #104 LIFIR o 593 5203
ADDRESS:
Edmonds 98020
BUSINESS OWNER: "Struck, Mary K." HOME PHONE: 2063659081 ACTIVE
EMERGENCY-1: HOME PHONE: "'CURRENT
KEY ACCESS-2: HOME PHONE: CITY YES NO
BUSINESS
LICENSE 11 11
K z INITIAL INSPECTION DATE
PERSON CONTACV:TED:. p) A A.AF I_dlol �4 A
NAME OF INSPECTOR: C
FIRE FE
SYSTEMS: ANNUAL
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
I st RE -INSPECTION
DATE DUE.
2nd RE -INSPECTION
DATE DUE.
EXTENSION
GRANTED TO-
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
1
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE,
DATE:
DATE:
3
VIOLATIONS
1 5
VIOLATIONS
1 5
PRE -CITATION
LETTER SENT
.1. CITATION ISSUED
NUMBER:
4
,2
6
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED
8
4
8
DATE:
DISPOSITION:
LETTER NEEDED C] YES NO
LETTER NEEDED C] YES [I NO,
8
FIRE DEPARTMENT COPY
v
CITY OF EDMONDS
121 5� AVENUE N. - EDMONDS, WASHINGTON 98020 - (425) 771-0215
FIRE DEPARTMENT
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LOCATION:
BUSINESS NAME: Struck, Mary Ma
MAILING 543 Main St #104
ADDRESS: Edmonds 98020
BUSINESS OWNER: w8truck, Mary K." HOMEPHONE: 2063659081
EMERGENCY- 1: HOME PHONE:
KEY ACCESS-2: HOME PHONE:
'6,h A-0 0A 14
FIRE PREVENTION
SAFETY SURVEY
104
PHONE: 4257718245
FREQUENCY
STATION& SHIFT
731
17 6
SCHEDULED
05/01/10
DATE DUE 11
UFIR o, 593
5203
ACTIVE
INITIAL INSPECTION DATE
PERSON CONTACTED:
NAME OF INSPECTOR:
FIRE FE I
:$YSTEWIS: ANKdZ
u
,HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
ENTER CODE ONLY ONCE ll�
VIOLATION CODE
2
2
3
3
4
4
5
5
6
6
7
7
. 8
8
lst RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTED TO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED.
PERSON
CONTACTED:
PERSON
CONTACTED:
1
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE-
DATE,
DATE-
3
VIOLATIONS
15
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:
7
8
k. LETTER NEEDED 0 YES C] N
LETTER NEEDED 0 YES NO
FIRE DEPARTMENT COPY