613 5TH AVE S13
5-IM Ave--
FIRE PREVENTION
'
Setving ffilet*,
_._.'s, and
1 112425 Meridian Ave S
INSPECTION REPORT
SNOHOMISH CO.
FIRE
. I . - I
Mountlake Terkrace-l-,
Everett, WA 98208
0 EDMONDS
0 BRIER
DISTRl�-"�--Tww-K�FireDistrictl.org..,
Phbne (425) 551-1200
[1 MOUNTLAKE TERRACE
0 UNINCORPORATED
Fax (425) 551-1272
FREQUENCY
STATION & SHIFT
LOCATION:
613 5th Avenue S 98020
2 Year
17-A
BUSINESS NAME:
Stephen Martin, DDS
PHONE: 4257767007,bATEDUE
SCHEDULED
II' Oct2013
MAILING
LIFIR � 593
ADDRESS:
6 13 5th Avenue S. Edmonds, V�-` b'8020
BUSINESS OWNER:
HOME PHONE:
EMERGENCY-11:
Martin, Stephen /I
HOME PHONE: 2064080916
CURRENT
KEY ACCESS-2:
HOME PHONE:
ClIT7 YES NO
C
TELICENSE
EMAIL:
fila (1h n 8'// Cg- CD,-M 6*�5-
BUSI NESS
PERSON CONTACTED:
INITIAL INSPECTION DATE
MAd(�;z
NAME OF INSPECTOR:
1::�el
FIRE SYSTEMS:
FEL_L/L
HAZARDS FOUND AND LOCATJONSV COMMUNICATIONS I
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41Z
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2
2
/0 Ll Z_
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4
4
5
5
6 wiiyl�_
6
7
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
lst RE -INSPECTION
2nd RE -INSPECTION
EXTENSION
FINAL RE -INSPECTION
VIOLATIONS
DATE DUE:
DATE DUE:
GRANTEDTO:
DATE DUE:
CITED:.
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
1
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
VIOLATIONS
PRE -CITATION
CITATION ISSUED
4
1 5
1 5
LETTER! SENT
NUMBER:
2
6
2
6
DATE:
CODE
SECTION:
5
3
7
7
RETURN RECEIPT
ECEIVED
6
-3
DISPOSITION:
4
DATE:
-4 .8
LETTERNEEDED F] YES NO
.8
LETTER NEEDED F] YES NO
8
FIRE DEPARTMENT COPY
S73
6&0 /06 tl_�
Inc.
CITY OF EDMONDS
INESS LICENSE APPLICATION— COMMERCIAL
FEE: $125.00
CITY CLERK'S OFFICE. BUSINESS LICENSE DIVISION
121 5' AVENUE NORTH, EDMONDS, WA 98020 PHONE: 425.775.2525
OFFICE USE ONLY
IBL#
Customer#
V�1'21.29 Fl�� -7
14c j
W 1,10
Lyear
/.2'1
I Class
6
I SHD
1
Date Paid
I TR#
Fee Paid
Mailed
Felete
1
INSTRUCTIONS: Please complete the application In full and attach the required floor plan. Middle Initial or name required of all
partles concerned. If no middle name, please Indicate by writing NMN. Sign and return application with fee. Please advise of
any change In status. Now license required If business changes location or ownership. Notification to City of Edmonds required
If business closes.
BUSINESS NAME I-C-- 9 0 MAI:z-j-iiJ f2.
6(2 :5�0,j
BUSINESS ADDRESS > L— 0 o- 0 ri IX W'A
Street
Suite No. Zip Code
MAILING ADDRESS F. 0 - R 0,< -3 2- 3 C- P rA 0 I'j o 5. k'd A . q 's !> 2,�
Street or PO Box Suite No. City, State and ZJp Code
BUSINESS PHONE NO. ( 42 T ) 7 '7 S - -7 ck=-' I_ WA STATE TAX ID NO. (UBI NO.) &101) 31529oq
Wcr
BUSINESS E-MAIL �-r U4 C AA A (2- T" d 9 1 1 Lei e. BUSINESS WEBSITE t�jo tj L:5-
PROPERTY OWNER e-: z> &j r- .3 1 fA c , -r-e e^ r2_—,pj Lir (Z- 5 LLC 689 - 2-D4'9_
Name Phone Number
EMERGENCY NOTIFICATION (For Premise Access in Emergency): 47- S;-
/\(\ rz T- i tJ ra r 1-4 C- '-4 14 7-0t, ) 4CIa C)9 $G
Last Name First Name MI Phone No.
IV\ A 01- T' I t-J r4 e�'� A 20& )
Last Name First Name MI Phone No.
NATURE OF BUSINESS 6C- r-J L;_ (—' r- L- DIF t-J TA -
NUMBER OF EMPLOYEES I SQUARE FOOTAGE OF BUSINESS SPACE
TYPE OF BUSINESS - PLEASE CHECK THE APPROPRIATE CATEGORY.
RIM
0 CONSTRUCTION 0 FINANCE, INSURANCE, REAL ESTATE 0 LANDSCAPE, HORTICULTURAL 0 MANUFACTURING 0 NON-PROFIT
0 RETAIL 0 SECONDHAND DEALER 0 SERVICES 0 WHOLESALE 0 OTHER
AMUSEMENT DEVICES ON PREMISES? 0 YES 99 NO IF YES, TOTAL NUMBER
& c- ,) LE &-, P, I - D G r4 T-A L_ &1 (4-* 14- 0
LIQUOR SOLD ON PREMISES?: 0 YES F2 NO GAMBLING? 0 YES PNO CIGARETTES SOLD ON PREMISES? 0 YES PPNO
FLAMMABLE OR HAZARDOUS MATERIALS USED OR STORED?: 0 YES 0 NO IF YES, PLEASE PROVIDE LIST OF MATERIALS AND QUANTITIES:
wi—ia5 DA10C 2
_2oej Le5
-Mju.�' Wail, r--1
PROPOSED OPENING DAY OF BUSINESS lf t 7- BUSINESS HOURS Ti— tt-� to —I :5"r 8-1 (A�,J.
DAYS OPEN 0 SUNDAY 0 MONDAY JOTUESDAY 14WEDNESOAY RTHURSDAY .5 FRIDAY .5 SATURDAY
PARKING SPACES ON SITE: MOr TOTAL ACCESSIBLE FOR PERSONS WITH DISABILITIES
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? 8 YES ONO
PREVIOUS BUSINESS USE AT THIS ADDRESS /V\ N 5 5 /A 41-'r 6- TI-A r__ r.?—A e t �' I— �
/\,\ p, t'j SOLE PROPRIETORSHIP
NAME :5 r L:-:: ol j4 u;: r�
Last First MI
ADDRESS I- I A 12- EF /k L-A t-� e L::* I,) w o M 0S anz.
Street -16 — D wrl, ' ApL.Np., Unit No. City, State and Mp Code 14 1+9 -7 V- IJ
-7 5t4'rj&r1)t'j e
HOME PHONE NO. A OL NO ((DRIVERS LICENSE NO.AR OTHER ID NO.
DATE OF BIRTH '0 A'; I /05�1 CITY AND STATE OF BIRTH- OUNTRYOFBIRTH ef f'"j t2 S
L-
PARTNERSHIP -PARTNER I
NAME
Lost First MI
ADDRESS
Street Apt. No., Unit No. City. State and Zip Code
HOMEPHONENO( ---DOL NO. (DRIVERS LICENSE NO.) OR OTHER 10 NO.
DATE OF BIRTH —CITY AND STATE OF BIRTH _COUNTRY OF BIRTH
PARTNER3HIP -PARTNER 2
NAME
Last First MI
ADDRESS
Street Apt. No., Unit No. City, State and Zip Code
HOME PHONE NO.L----J_ DOL NO. (DRIVERS LICENSE NO.) OR OTHER ID NO.
DATE OF BIRTH CITY AND STATE OF BIRTH COUNTRY OF BIRTH
CORPORATION
NAME OF CORPORATION FEDERAL TAX ID NO.
CORP. ADDRESS Street Suite. Apt., Unit No. City, State and Zip Code PHONE NO.(
CORPORATE OFFICERS:
Last Name First Name MI Tide Date of Birth DOL No. (Drivers License No.) or Other ID No.
LOCAL CONTACT
Last Name First Name MI Title Phone No. DOL No. (Drivers Lie. No.) or Other ID No,
'q, /
APPLICANT 0 14. bw 0 a e—> I/ -- 5/t 2w
Name — Printed Signature Title Uale
PLANNING DEPT. 0 APPROVE 0 DISAPPROVE DATE —SIGNATURE
ZONING CODE CONDITIONAL USE PERMIT
COMMENTS
BUILDING DEPT. 0 APPROVE 0 DISAPPROVE DATE ----..§IGNATURE
OCCUPANTLOAD UILDING PERMIT CCUPANCY GROUP
COMMENTS
FIRE DEPT. 0 APPROVE 0 DISAPPROVE DATE SIGNATURE
I.I.F.I.R.
COMMENTS
POLICE DEPT. 0 APPROVE 0 DISAPPROVE DATE IGNATURE
COMMENTS
.*Lelbsohn &Company
Cl
Lelbschn & Company
40 Lake Bellevue Drive, Suite 270
Bellevue, WA 98005
Phone: (425) 455-1777
Fax: (425) 455-2196
LEASE AGREEMENT
Multi Tenant Triple Net (NNN Lease)
EXHIBIT A
[Outline of the Premises]
FLOORPLAN FIRST FLOOR
iAs Measured: November 24, 2004)
jTcMj.U46A WAr TEL! (2W)328-7410
0 Commeroal Brokers
Association 2011
ALL RIGHTS RESERVED (24("
CEA Form k4T-NNN
MuRI-Tenent NNIN Lease
Rev. 312011
Page 25 of 27
FIRE PREVENTION
Seii)ing Briei; Ubionds
12425 Met-idian Ave S
INSPECTION REPORT
SNOHOMISH CO.
OTIRE
Mountlake Terraceand
c1f,
Everett, WA 98208
0 EDMONDS
0 BRIER
e Town of Woodway
Phone (425) 551-1200
0 WOODWAY
MOUNTLAKE TERRACE
DIST6
T wtww.FireDistrictl.org
Fax (425) 551-1272
0
0 UNINCORPORATED
e' FREQUENCY STATION & SHIFT"'
LOCATION:
613 5th Avenue
S
731 1 7
I
VAC -ANT
BUSINESS NAME:
-,ft"hwv44@9Wi.Spa
PHONE: 42577131234
SCHEDULED
DATE DUE 11' 10/01/11
MAILING
613 5th-Ave S
LIFIR � 559 1(153
ADDRESS:
Edmonds
98020
BUSINESS OWNER:
Day enterprises
HOME PHONE: 2065420900
ACTIVE
EMERGENCY-1:
Hofmann, Arnold
HOME PHONE: 4253431519
CURRENT
KEY ACCESS-2:
Day, Roger
HOME PHONE: 2065420900
CITY YES NO
BUSINESS
0 F
LICENSE
PERSON CONTACTED: NV C'O k) 7`4 C4
INITIAL INSPECTION DATE
OF
NAME INSPECTOR:
FIRE
FE 1
SYSTEMS:
ANNUAL
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
1 tj 0 &
2
2
3
3
4
4
5
5
6
6
7
7
1 AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
lst RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
D E 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
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
�l LETTER NEEDED [] YES NO
LETTER NEEDED C] YES NO
8
FIRE DEPARTMENT COPY