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FIRE PREVENTION
INSPECTION REPORT
ONIISH CO
Serving Brier, Edmurw.5, and 12425 Meridian Ave S
SNOR----6EDMONDS
Mountlake Terrace Everett, 'WA 98208 0 BRIER
FIRE 0 MOUNTLAKE TERRACE
Phone (425) 551-1200 ❑
[1 UNINCORPORATED
DISTRIUT www.FireDistrictl.org Fax (425) 551-1272
1155th Avenue S 98020
LOCATION:
Legendary Properties
BUSINESS NAME:
MAILING 115 5th Avenue S, Edmonds, WA 98020
ADDRESS:
BUSINESS OWNER:
Blevins, Kirk
EMERGENCY -I:
KEY ACCESS-2-
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PERSON CONTACTED: r r V, -,j� c It j i --s )
NAME OF INSPECTOR:
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4257715180
PHONE:
HOME PHONE:
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4258766944
HOME PHONE: 17
HOME PHONE:
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SCHEDULED May 2017
DATE DUE
59 1 203
LIFIR
CURRENT NO
CITY
BUSINESS
LICENSE
INITIAL INSPECTION DATE
Lt _ --Z 1.( .- 1 -1
1
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Serving Brier, -Edmonds, and
Mountlake Terrace
www.FireDistrictl.org
LOCATION:
115 5 th Avenue S 98020
BUSINESS NAME:
Legendary Properties
MAILING
ADDRESS:
115 5th Avenue S, Edmonds, WA` 98020
BUSINESS OWNER:
FIRE PREVENTION
12425 Meridian Ave S INSPECTION REPORT
` EOMONDS
Everett, WA 98208 ❑ BRIER
Phone (425) 551-1200 ❑ MOUNTLAKE TERRACE
Fax (425) 551-1272 [I UNINCORPORATED _
FREQUENCY STATION & SHIFTr,;•, .
PHONE: SCHEDULED
4257715180 DATE DUE ►
UFIR /
591 203
HOME PHONE:
EMERGENCY-1: HOME PHONE: CURRENT
KEY ACCESS-2: Blevins, Kirk HOME PHONE: 4258766944 CITY YES NO
EMAIL: __ k i r K b 1 ev A52 �`c o �-D A-1. LB S CEINSE ❑
INITIAL INSPECTION DATE
PERSON CONTACTED:
NAME OF INSPECTOR:45-1
FIRE SYSTEMS:. FE 9/13
DstakautcSwAaedowiONS / COMMUNICATIONS
2 11-7-& 1030 AYLI Gs OS&A
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I AGREE TO.CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS
1st RE -INSPECTION
2nd RE -INSPECTION
ENSION
FINAL RE -INSPECTION
VIOLATIONS
DATE DUE:
DATE DUE:
GRANTED TO:
DATE DUE:
CITED:
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PERSON r
CONTACTED:
PERSON
CONTACTED:
PERSON
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1
INSPECTOR:
INSPECTOR: -+'
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
VIOLATIONS` ^ t
PRE CITATION
CITATION ISSUED
1 5
1 5
LETTER SENT
NUMBER:
4
2
6
2
6
DATE:
CODE �^
SECTION: L'• `
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6 is
3
7
3
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ECEIVEDRECEIPT
DISPOSITION:
4
8
4 18
DATE:
LETTER NEEDED ❑ YES ❑ NO
LETTER NEEDED ❑ YES ❑ NO
6
0
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 1
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 10 NO.
DATE OF BIRTH CITY AND STATE OF BIRTH � COUNTRY OF BIRTH
PARTNERSHIP - PARTNER 2-
NAME
Last -First MI
ADDRESS
Street Apt. No., Unit No. City, State and 7Jp Code
HOME PHONE NO.( j DOL NO. (DRIVERS LICENSE NO.) OR OTHER10 NO:
DATE: OF BIRTH CITY AND STATE OF BIRTH COUNTRY OF BIRTH
CORPORATION f
NAME OF CORPORATION t.. CAN D AQ�_ �� RTC �C _.. FEDERAL TAX ID NO. y 4 — S14 I�
CORP. ADDRESS I I .r A U �rr) w DS Q $ OZC�_ _ - PHONE NO.( L
Street Suite, Apt.. Unit No. City; St6teland Z p Code
CORPORATE OFFICERS:
Last Wine First Name MI Title 0 No.
lEyI&,s
LOCAL CONTACT SL�V I K1 �� G�hL jT Q�L ''SID�yC (� S7�O�Co
Last Name First Name MI Tille Phone No. DOL No. (Drivers Lic. No.) or o.
Name —Printed I n to Tille Date
CRY, USE- ONLY: .,
-
OLANNING-DEPT. 'd-APPROVE:=
. b'DISAPPROVI;
DATE -
SIGNATURE`
ZONING C0DE - '
CONDITIONAL USE' PERMIT
•COMMENTS ` '
.. � . '. • -' -
. 8UILDING:OEPT. 0-APPROVE
O DISAPPROVE
DATE
OCCUPANT LOAD'
BUILDING PERMIT_
.:SIGNATURE:
_ OCCUPANCY GROUP
COMMENTS
FIRE DEPT. O APPRQVE
O DISAPPROVE
DATE
SIGNATURE— • __
COMMENTS
POLICE DEPT. O•APPROVE
O DISAPPROVE
DATE
SIGNATURE
COMMENTS
II Air -
CITY
I ' E1♦ ` OF ,.EDMONDS
121 5T" AVENUE N. • EDMONDS, WASHINGTON 98020 (425) 771-0215
FIRE DEPARTMENT
�S.t.
LOCATION: 115 5th Avenue
i
I
BUSINESS NAME: Edrno ds Homestead Coffee
r
y MAILING ` rr$h 11w C�-
FIRE PREVENTION
SAFETY SURVEY
PHONE: 42 786823
I ADDRESS: �
Edmonds �� 9�aD2O
BUSINESS OWNER: Harris, Mike HOME PHONE: 2063633640
f .
EMERGENCY-1:' HOME PHONE:
I KEY•ACCESS-2: , HOME PHONE:
i
FREQUENCY STATION & SHIFT
731 17 A
t
SCHEDULED �a,,�
DATE DUE ►
UFIR ► 5-15 169 5 203
ACMVE
-1 =�;" . INITIAL INSPECTION DATE
PERSON CONTACTED:
NAME OF INSPECTOR:
FIRE F f
SYSTEMS: " _ANNUAL
HAZARDS FOUND AND LOCATIONS ! COMMUNICATIONS
ENTER CODE ONLY ONCE. ► - .
'' VIOLATION CODE
1
•
1
2
_
2
tw__
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3 �` (
3.
4
4
5
5
6
6
7
7
8
8
1st RE -INSPECTION
2nd RE -INSPECTION
EXTENSION
FINAL RE -INSPECTION
VIOLATIONS
GRANTED TO:
CITED:
DATE DUE:
DATE DUE:
PERSON
DATE DUE:
PERSON
PERSON
CONTACTED:
CONTACTED:
INSPECTOR:
DATE:
VIOLATIONS
CONTACTED:
1
INSPECTOR:
INSPECTOR:
DATE:
2
DATE:
3
VIOLATIONS
PRE -CITATION
CITATION ISSUED
1 5
1 5
LETTER SENT
NUMBER:
'CODE
4
2
6
2 6R
DATE:
SECTION: _
5
6
RETURN RECEIPT
3
7
3 7
RECEIVED
�
7
��
DISPOSfTION:
4
8
4 .8 `
DATE:
`
LETTER NEEDED E] YES NO
LETTER NEEDED YES NO z�
8
FIRE DEPARTMENT COPY