110 W DAYTON ST STE 201_Redacted��������� 1► 0 cJ Djy`raA1 Si S r a71// FIRE PREVENTION
i Serving Brier, Ec... _ _ . _ ___., 7 12425 Meridian Ave S INSPECTION REPORT
Mountlake Terrace,and k EiWe'tt; ''WA (� 98208 EDMONDS
BRIER
the Town of Woodway Phone (425) 551-1200 ❑ WOODWAY
❑ MOUNTLAKE TERRACE
0011"TwwwFireDistrictLorg Fax (425) 551-1272 ❑UNINCORPORATED
FREQUENCY I STATION & SHIFT
LOCATION: 110 West Dayton Street Suite 201 9$020 2 Year 13 17-8
BUSINESS NAME: Amenity Serices/WP Coffee PHONE: 4257787801 SCHEDULED Sep
DATE DUE
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MAILING UFIR / 591
ADDRESS:
110 West Dayton Street, Suite 201, Edmonds, WA 98020
BUSINESS OWNER:
Email:
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HOME PHONE:
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EMERGENCY-1: 1`y S7'D V L 1 L
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HOME PHONE:
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LICENSE
PERSON CONTACTED:A:116
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INITIAL INSPECTIO ATE
NAME OF INSPECTOR:
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I AGREE TO CORRECT THE ABOVE VIOLATIONS) IN THE NEXT 30 DAYS X
1st RE -INSPECTION
2nd RE -INSPECTION
EXTENSION
FINAL RE -INSPECTION
VIOLATIONS
DATE DUE:
DATE DUE: jr
GRANTED TO:
DATE DUE:
CITED:
PERSON
PERSON
PERSON
CONTACTED:
CONTACTED: '
CONTACTED:
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
• VIOLATIONS
VIOLATIONS
PRE -CITATION
CITATION ISSUED
4
1 5
1 5
LETTER SENT
NUMBER:
CODE
5
2
6
2
6
DATE:
SECTION:
RETURN RECEIPT
6
3
7 _
3
7
RECEIVED
DISPOSITION:
4
8
5
4
8
DATE:
LETTER NEEDED ❑ YES ❑ NO
LETTER NEEDED ❑ YES ❑ NO
8
FIRE DEPARTMENT COPY
Sit I 680 Q y 6 °z.o-z
CITY OF EDMONDS
BUSINESS LICENSE APPLICATION- COMMERCIAL
FEE: $125.00
/\ CITY CLERK'S OFFICE, BUSINESS LICENSE DIVISION
f'��• I� °�) tV,,/ 121 5j" AVENUE NORTH, EDMONDS, WA 98020 PHONE: 425.775.2525
_ OFFICE USE ONLY _
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INSTRUCTIONS: Please 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.
BUSINESS NAME
BUSINESS ADDRE
MAILING ADDRESS _ Di-6t_ I•L4_y_,,.,,
�jStreet or PO Box ! Suite No. City, State and Zip Code
7-7
BUSINESS PHONE NO. ( d i ) j {ra Li� WA STATE TAX ID NO. (UBI NO.)
BUSINESS E-MAIL BUSINESS WEBSITE
PROPERTY OWNERG
Name Phone Number
EMERGENCY NOTIFICATION (For Premise ccess in Emergency):
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Last Name �, , just Name MI Phone No.
Last Name First Name Mi P one No.
NATURE OF BUSINESS k- - 6 _
NUMBER OF EMPLOYEES SQUARE FOOTAGE OF BUSINESS SPACE - ,) 3
TYPE OF BUSINESS - PLEASE CHECK THE APPROPRIATE CATEGORY.
O CONSTRUCTION O FINANCE, INSURANCE, REAL ESTATE O LANDSCAPE, HORTICULTURAL O MANUFACTURING D NON-PROFIT
O RETAIL O SECONDHAND DEALER D SERVICES 1IYHOLESALE O.OTHER _
AMUSEMENT DEVICES ON PREMISES? . D YES NO - IF YES, TOTAL NUMBER _
LIQUOR SOLD ON PREMISES?: D YES . NO . ' GAMBLING? D YES NO CIGARETTES SOLD ON PREMISES? D YES NO
FLAMMABLE OR HAZARDOUS MATERIALS USED OR STORED?: ❑ YES 'NO IF YES; PLEASE PROVIDE LIST OF MATERIALS AND QUANTITIES:
PROPOSED OPENING DAY.OF BUSINESS BUSINESS HOURS _� �Lp 7 •�c'� Y a''�
DAYS OPEN O pk�AONDAY TUESDAY `
WEDNESDAYJ THURSDAY K� FRIDAY D SATURDAY
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PARKING SPACES ON SITE: TOTAtt-C�--fj •�V ��'.t,� f* . ACCESSIBLE FOR PERSONS WITH DISABILITIES
�.
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES?. `YES O NO
PREVIOUS BUSINESS USE AT THIS ADDRESS /
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Exhibit "A"
UARLIOR SQUARE. BUSINESS PARK
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CITY OF EDMONDS ECON 0P_.
BUSINESS LICENSE APPLICATION- COMMERCIAL FIRE ," Q
-MAYOR
FEE: $125.00 PLAN - -�
CITY CLERK'S OFFICE, BUSINESS LICENSE DIVISION POLICE
121 5T" AVENUE NORTH, EDMONDS, WA 98020 PHONE: 425.775.2525 T.- U77L EU
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OFFICE USE ONLY
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INSTRUCTIONS: Please 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.
BUSINESS NAME - r���%f �'Gr�✓ices /� a
BUSINESS ADDRESS ) --3
Street / Suite No_ Zip Code
MAILING ADDRESS xt /
Street or PO Box Suite No. City, State and Zip Code 7
,BUSINESS PHONE NO. )_, 4? ' d0WA STATE TAX ID NO. (UBI NO.) C!/ D
BUSINESS E-MAIL ld $6/1 /11f ; v BUSIN SS WEBSITE /% /1� /[C IS : 6 D✓N
PROPERTY OWNER V 1/ d��/i'L 4' S 7�
Name Phone Number
EMERGENCY NOTIFICATION (For Premise Access in Emergency):
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Last Name First Name MI Phone No.
Last Name First Name �Mti Phone N`o.
NATURE OF BUSINESS d 4- QIY1Gq' /O le / 4
NUMBER OF EMPLOYEES /o SQUARE FOOTAGE OF BUSINESS SPACE
TYPE OF BUSINESS - PLEASE CHECK.THEAPPROPRIATE CATEGORY.
O C5PRSTRUCTION O FINANCE, INSURANCE, REAL ESTATE O LANDSCAPE, HORTICULTU.4AL O MANUFACTURING C :JON-PROFIT
(1�4iTAIL O SECONDHAND DEALER O SERVICES O WHOLESALE_ O.OTHER
AMUSEMENT DEVICES ON PREMISES? .O YES ffi'NO . IF YES. TOTAL NUMBER
LIQUOR SOLD ON PREMISES?: O YES . (9'NO, GAMBLING? O YES 9<0 CIGARETTES SOLD ON PREMISES? O YES 01NO
FLAMMABLE OR HAZARDOUS MATERIALS USED DR STORED?: O YES V11<O IF YES, PLEASE PROVIDE LIST OF MATERIALS AND QUANTITIES:
PROPOSED OPENING DAY OF BUSINESS BUSINESS HOURS _7. '3��9 �• 3 d
DAYS OPEN O SUNDAY MONDAY VTUESDAY WJ WEDNESDAY THURSDAY )&RIDAY -O SATURDAY
PARKING SPACES ON SITE: TOTAL ACCESSIBLE FOR PERSONS WITH DIIS ILITIES C S
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES?. BYES O NO -
PREVIOUS BUSINESS USE AT THIS ADDRESS
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CITY OF EDMONDS
woo 121 5TM AVENUE N. • EDMONDS, WASHINGTON 98020 • (425) M-0215
FIRE DEPARTMENT
Est 1ag0
LOCATION:
110 W. Dayton Street
BUSINESS NAME:
Amenity ServlcesMlP Coffee
MAILING
110 W. Dayton St #201
ADDRESS:
Edmonds
BUSINESS OWNER:
Stoulil Don
EMERGENCY-1:
StoUlll, Ryan
KEY ACCESS-2:
FIRE PREVENTION
SAFETY SURVEY
201
PHONE: 4257787891
98020
HOME PHONE: 2062957641
HOME PHONE: 2063104925
HOME PHONE:
FREQUENCY
STATION & SHIFT
730
17 C
SCHEDULED
D9/0111 D
DATE DUE ►
UFIR ► 591
9202
ACTIVE
PERSON CONTACTED: " N� INITIAL INSPECTION DATE
NAME OF INSPECTOR: j , to - lb
FIRE FE L!j Q
SYSTEMS:
ANNUAL
HAZARDS FOUND AND LOCATIONS /COMMUNICATIONS
N 4 Tlb 4 `:.. F4 4
ENTER CODE ONLY ONCE ►
VIOLATION CODE
,
2
2
3
3
4
4
5
5
6
A
6
7
7
8
8
1st 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
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
LETTER NEEDED ❑ YES NO
LETTER NEEDED ❑ YES NO
FIRE DEPARTMENT COPY