545 MAIN ST (2)SNOHOMISH CC
FIRE
I)IST
InAW (f 7-
Seri,ingBriet; Edn,_.._._, ....d 12425 Meridian Ave S
Mountlake Terrace Everett, WA 98208
Phone (425) 551-1200
www.FireDistrictl.org Fax (425) 551-1272
LOCATION: 545 ' Main Street 98020
BUSINESS NAME: Edmonds Fami!y Dentistry
MAILING
ADDRESS: 545 Main Street, Edmonds, W.4� �2180210
PHONE: 4255827115
FIRE PREVENTION
INSPECTION REPORT
RIEDMONDS
0 BRIER
0 MOUNTLAKE TERRACE
0 UNINCORPORATED
r FREQUENCY STATION & SHIFF"'
2 Year 14 17-8
SCHEDULED
DATE DUE 041sy2014
LIFIR o593 203
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BUSINESS OWNER: HOME PHONE:
H 2-1";
EMERGENCY-1: HOME PHONE:
aeir�onq_ �o6lay-� CURRENT
KEY ACCESS-2: HOME PHONE: CITY YES NO
EMAIL: BUSINESS
LICENSE
PERSON CONTACTED: INITIAL INSPECTION DATE
NAME OF INSPECTOR: Z/-'27
FIRE SYSTEMS: Fp
H RD, F U D AND LOCATIONS /COMMUNICATIONS
A yi k2
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
�IY\4�All
I I
1st RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTEDTO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACT D:
PERSON
CONTACTED:
PERSON
CONTACTED:
1
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
5
VIOLATIONS
1 15
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
I LETTER NEEDED E] YES [I NO
8
FIRE DEPARTMENT COPY
CITY OF EDMONDS tJLDG�
ECON
E
i��'�JRLI,S!,NE§S LICENSE APPLICATION- COMMERCIAL
FEE: $125.00 MAYOR
CITY CLERK'S OFFICE, BUSINESS LICENSE DIVISION PLAN
Inc. POLICE
V,9 121.5' AVENUE NORTH, EDMONDS, WA 98020 PHONE: 425.775.2525 UTIL BILL
S?3 bec) exrg
OFFICE USE ONLY
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INSTRUCTIONS: Pleas6 complete the application in full and attach the required floor plan. Middle initial or name required of all
parties concerned. If no middle name, please indicate by writing NMN. Sign and return application with fee. Please advise of
any change in status. New license required If business changes location or ownership. Notification to City of Edmonds required
if business closes.
BUSINESSNAME &tMOVI
BUSINESS ADDRESS
MAILING ADDRESS
Cgo-)-cl.
Suite No- Zip Code
Street or PO Box Suite No. City, State and Zip Code
BUSINESS PHONE NO. WA STATE TAX ID NO. (UBI NO.)
BUSINESS E-MAILQ#ioy)d&c-s/&fT 4
BUSINESS WEBSITE
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PROPERTY OWNER _'1 SYP
_B,yvan 'nd rSety 102,—q
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Name Phone Number
EMERGENCY NOTIFICATION (For Premise.Access in Emergency):
ko Vc-oairglq - ) ea--L- - S-V / 0
Last Name First N�me MI Phone No.
Last Name Fi6ft Name Mi Phone No.
NATURE OF BUSINESS
NUMBER OF EMPLOYEES SQUARE FOOTAGE OF BUSINESS SPACE _/h_0
TYPE OF BUSINESS - PLEASE CHECK THE APPROPRIATE CATEGORY:
• CONSTRUCTION 0 FINANCE, INSURANCE, REAL ESTATE 0 LANDSCAPE, HORTICULTURAL 0 MANUFACTURING 0 NON-PROFI T
• RETAIL 0 SECONDHAND DEALER XSERVICES. 0 WHOLESALE 0 OTHER
AMUSEMENT DEVICES*ON PREMISES-? '0 YES KNO IF YES, TOTAL NUMBER
LIQUOR SOLD ON PREMISES?: 0 YES "0 GAMBLING? 0 YES' JKNO CIGARETTES SOLD ON PREMISES? 0 YES JXNO
FLAMMABLE OR HAZARDOUS MAT ERIALS USED OR STORED?: AYES C3 NO IF YES, PLEASE PROVIDE LIST OF MATERIALS AND QUANTITIES:
41,0
PRoPbSED OPENING DAY OF BUSINESS 0 BUSINESS HOURS 10-1
DAYS OPEN KSUNDAY O[MONDAY OTUESDAY PfWEDNESDAY ATHURSDAY R FRIDAY - _KSATURDAY
PARKING SPACES ON SITE: TOTAL —3 -ACCESSIBLE FOR PERSONS WITH DISABILITIES
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESS18LE TO PERSONS WITH DISABILITIES? AYES 0 No
PREVIOUS BUSINESS USE AT THIS ADDRESS 1912n�7a/
SOLE PROPRIETORSHIP
NAME
Last First MI
ADDRESS
Street Apt. No., Unit No. City, State and Zip Code
HOME PHONE NO. ____.�DOL NO. (DRIVERS LICENSE NO.) OR OTHER ID NO.
DATE OF BIRTH CITY AND STATE OF BIRTH -COUNTRY OF BIRTH
PARTNERSHIP -PARTNER I
NAME__kQN
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Last
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6�—
First
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WA
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AD DRESS ?n
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Street Apt. No., Unit No. City, Stbte and Zip Code
HOME PHONE NO.(q,��) I q5 DOL NO. LICENSE NO.) OR OTHER ID NO. A4 * ?� 9 q
0 3
(DRIVERS
3 41-3 113,
SC-oUL
/-' A
DATE OF BIRTH CITY AND STATE OF BIRTH .
COUNTRY OF BIRTH
PARTNERSHIP - PARTNER 2
NAME
Last
w
First C/
jft--4
MI
ADDRESS
Street Apt. No., Unit No.
HOME PHONE NO.(L-4 11S_ —13 4 q DOL NO. LICENSE NO.) OR OTHER ID NO.
City, State and Zip Codd
WAL 1, A !14 ;�q "I
(DRIVERS
DATE OF BIRTH zq 9 1 — CITY AND STATE OF BIRTH,5d=Ad�
COUNTRY OF BIRTH
CORPORATION
NAME OF CORPORATION FEDERAL TAX ID NO.
CORP.ADDRESS PHONE NO.(
Street Suite, Apt., Unit No. City, State and Zip Code
CORPORATE OFFICERS:
Last Name First Name MI Title Date of Birth DOL No. (Drivers License No.) or Other ID No.
LOCAL CONTACT
Last Name First Name
f�_] T-itle Phone No. DOL No. (Drivers Lic. No.) or Other ID No.
�fflx C,/
PAM'
WIM 11 —Dit
Title e
CITY. USE ONLY:
PLANNING DEPT.
0 APPROVE
0 DISAPPROVE
DATE
SIGNATURE
ZONING CODE
CONDITIONAL USE PERMIT
COMMENTS
BUILDING DEPT.
0 APPROVE
0 DISAPPROVE
DATE
SIGNATURE
OCCUPANTLOAD
BUILDING PERMIT
OCCUPANCY GROUP
COMMENTS
FIRE DEPT.
0 APPROVE
0 DISAPPROVE
DATE
SIGNATURE
I.I.F.I.R.
COMMENTS
POLICE DEPT.
0 APPROVE
D DISAPPROVE
DATE
SIGNATURE
COMMENTS
Office
Customer
Counter
Reception Area
Exit
Family Room Sterilization Office
I Room I
Operating Operating
Room 1 1 Room 2
Rest I X-Ray I Dental
Room I Room I LAB
Break Room Storage
I Room
Develbper
Room
Exit