21010 80TH PL WSNOHOMISH CO.
FIRE
DISTR T
0 P
FIRE PREVE ' NT ' ION
Sei-ving Bilei; and 12425 MeridianAve S
INSPECTION REPORT
K.
Mountlake Tet-mce Everett, WA 98208
0 EDMONDS
0 BRIER
Phone (425) 551-1200
0 MOUNTLAKE TERRACE
wwwFireDistrictl.org Fax (425) 551-1272
0 UNINCORPORATED
FREQUENCY
STATION & SHIF"I
LOCATION:
21010 80 th Place W 98026
Annual
I
I&B
BUSINESS NAME:
Wlson TriDlex
PHONE:
2065250473
SCHEDULED Feb 2014
DATE DUE 0
MAILING
LIFIR422 206
ADDRESS:
462 NE 70th, Seattle, WA 98115
BUSINESS OWNER:
Wlson, Robert
HOME PHONE:
EME . RGENCY-1:
Wilson, Glenda
HOME PHONE:
2069387041
CUR —RENT
KEY ACCESS-2:
HOME PHONE:
CITY
YES No
BUSINESS
0
El
EMAIL:
LICENSE
PERSON CONTACTED:
INITIAL CTION
17z,7z�,
NAME OF INSPECTOR:
.1
FIRE SYSTEMS:
E 2113 HD
IV R, L,2
HAZARDS FOUVD AND LOCATIONS / COMMUNICATIONS
1;. 0 /v f_:11
FZ
Nc- E:::-t-2 r— C_ J 6__
2 Tn�
3
L 0 S,
1
2
3
4
5
6
-1 ------
4
5
6
7
LJ
7
I AGREE TO CORRECT THE ABOVE VIOLAT16N(S) IN THE NEXT 30 DAYS X
1 S1 RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTEDTO:
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
2 6
PRE -CITATION
LETTER SENi
CITATION ISSUED
NUMBER:
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED
6
4
8
4
8
DATE:
DISPOSITION:
7
LETTER NEEDED [] YES NO
LETTER NEEDED [-] YES NO
8
FIRE DEPARTME , NT COPY
FIRE PREVENTION
Serving Brier, Edmonds
12425 Meridian Ave S
INSPECTION REPORT
SNOHOMISH CO.
FIRE11'"
Mountlake Terraceand
Everett, WA 98208
-R-EDMONDS
El BRIER
STR
- the Town of Woodway
T
Phone (425) 551-1200
13WOODWAY
0,MOUNTLAKE TERRACE
www.FireDistrictl.org
Fax (425) 551-1272
0 UNINCORPORATED
FREQUENCY
STATION & SHIFT�
LOCATION:
21010 80th Place
W
365
16 A
BUSINESS NAME:
Wilson Triplex
PHONE: 2065256473
SCHEDULED
U
DATE DUE � 02/01/13
MAILING
462 NE 70Th
UFIR 11, 422 2206
ADDRESS:
Seattle
98115
BUSINESS OWNER:
Wilson, Robert A"
HOMEPHONE: 2065256473
ACTIVE
EMERGENCY-1:
"Wilson, GR
2069387041
HOME PHONE:
CURRENT
KEY ACCESS-2:
HOME PHONE:
CITY YES NO
BUSINESS
LICENSE
PERSON CONTACTED:
INITIAL INSPECTION DATE
OF INSPECTOR:
ANAME
FIRE
FE 2-
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
1st RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
0 E DUE:
EXTENSION
GRANTED TO:
FINAL RE -INSPECTION
DATE DUE:
IC
VIOLAT ONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
E
DAT : �
DATE:
3
'VIOLATIONS
1
LATIONS
1 nit 15
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
.2
6
2 Uf
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED
6
4
18
4
8
DATE:
DISPOSITION:
7
LETTER!4EEDED [-] YES NO
- LETTER NEEDED C] YES NJO
8
FIRE DEPARTMENT COPY
Serving Brier, Edmonds
SNOHOMI13H CO.
FIREI
4 Mountlake Terraceand
ST IVA"
the Town of Woodway
www.FireDistrict].org
- LOCATION:
21010 80th Place
BUSINESS NAME:
Wilson Triplex
MAILING
462 NE 70Th
ADDRESS:
Seattle
BUSINESS OWNER:
Wilson, Robert W
EMERGENCY-1:
"Wilson, Gn
KEY ACCESS-2:
PERSON CONTACTED:
NAME OF INSPECTOR:
FIRE
SYSTEMS:
W
12425 Meridian Ave S
Everett, WA 98208
Phone (425) 551-1200
Fax (425) 551-1272
PHONE: 2065256473
98115
HOME PHONE: 20652563473
HOME PHONE: 2069387041
HOME PHONE:
0 0 LA) I- I A) C) � 6 r�: I A)
0 (b I A) 5 QA)
FIRE PREVEN I
INSPECTION REPORT
0 EDMONDS
0 BRIER
OWOODWAY
0 MOUNTLAKE TERRACE
0 UNINCORPORATED
FREQUENCY I STATION & SHIFF`*1
365 16 D
SCHEDULED 112/01/12
DATE DUE
UFIR 1, 422 2206
ACTIVE
CURRENT
CITY YES NO
BUSINESS
LICENSE El 1:1
INITIAL INSPECTION DATE
I 10 / Z_
FE LO/ 07
ANNUAL
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
AAl IvOA L A"�
� j/7v
2
�6,tl
2
V
3
4
3
__2
4
4
5
LL11- 0
5
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6
ry
6
r
7
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
V
In our continuning effort to promote fire safety and prevention within the community, your fire department conducts
regularly scheduled "Fire Safety Survey Inspections" of all businesses and multi -family occupancies in the Cities
covered by Snohomish County Fire District'l.
You are to be congratulated on the relative good condition of your occupancy in regards to fire safety. Above you
will find the item(s) that were noted during our inspection which require attention to bring them into compliance
with the minimum standrads adopted by the above jurisdictions.
Any overlooked hazards or violations of the fire regulations does not imply approval of such conditions or violation.
If you require additional information or to schedule a re -inspection for Edmonds or the Town of Woodway, call
(425) 775-7720; for Mountlake Terrace or Brier, call (425) 754-0434.
BUSINESS COPY
�1
I t"'
a
FIRE PREVENTION
SAFETY SURVEY
C1W OF EDMONDS
121 5TH AVENUE N. - EDMONDS, WASHINGTON 98020 - (425) 771-0215
FIRE DEPARTMENT,
t , 1 0
LOCATION: 21110 80th Place W
13USINESS NAME: Northwest Family Homes PHONE: 4257744444
MAILING POB #839
ADDRESS: Lvnnwood 98046
FREQUENCY STATION & SHIFT
365 16 C
SCHEDULED
DATE DUE 01
UFIR i� 321
BUSINESS OWNEW Northwestern Family Homes Inc HOMEPHONE: 4257744444 ACTIVE 6
"Bennett, Jean L" 4257744444
EMERGENCY-1: HOME PHONE:
KEY ACCESS-2: HOME PHONE:
PERSON. CONTACTED: INITIAL INSPECTION DATE
NAME OF INSPECTOR: W,4(�Ac-pj ql)fo
CID= FA Aln7 A4z ?inn
SYSTEMS:
A�NUZ
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
1
ENTER CODE ONLY ONCE 1�
VIOLATION CODE
2
2
C)
3
3
4
4
5
5
6
v
6
7
7
8
8
1st RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
1
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
7
4
Is
4
8
DATE:
DISPOSITION:
-
8
LETTER NEEDED [] YES NO
LETTER NEEDED E] YES 0 NO
FIRE DEPARTMENT COPY
WX 11 1=1 Imam- W4
Rpr 11 11 10:11a Northwestern Famil�j Home 4253550101 P.1
FAXFrom Northwestern
Family Homes, INC.
DATE: -//-/I
FAX TO:
FAX #: f Cy
# OF PAGES: GoOer
COMMENTS: za&�L/C)A-L,
-7//0
NORTHWESTERN FAMILY HOMES, INC.
P.O. Box 839 Lynnwood, WA. 98046
Phone: (425) 774-4444 Fax: (425)355-0101
This facsimile document may contain person health information
belonging to the sender which is highly confidential. This
information is protected by the privacy of the patient privilege:
This information is only intended for exclusive use by the above
name addressee. it is.to be used only to aid in providing specific
healthcare services to this patient. Another use of this confidential
information is a violation of federal law (HIP AA) and will be
reported as such. if you are not the intended recipient you are
hereby notified that any disclosure, copying, distribution or the
taking of any action in responses to this facsimile transmission in
error. Please notify us as soon as possible.
Thank you
Apr 11 11 10:11a Northwestern Famil�j Home 4253550101 p.2
A
AN
=WPIAT nz_VG
Q I I Aect. #:
574261
Fire Protection, Inc. (425) 290-9600
CONTRACTOR #FIREPI*021ML (800) 681-1125
1730 Gibson Road Fire and Security Alarm Installations
Everett, WA 98204 24 Hour Local UL Monitoring Fax: (425) 353-4546
FIREALARM SYSTEM
Certification Given
(One System per Report)
YELLOW
WHITE
d'CONFIDENCE TEST
:1 REPAIRS
L J
Occupancy Address:
Occupancy Name,
Phone Number:
-7/i
Responsible Party
Date of Inspection:
' //1?
E-mail Address:
Testers Name: Illckitfic �4c,"ior--r-
Inspection Frequencyfrype: Monthly
11 1 1 1
�Aq il"Ot&y
C3 Quarterly
Q Semi -Annual
Ja Annual
SFD Certification Number: SCP- ZO 7 5- 7 -7
Cenfral station monitoring? 6 Yes C3 No
Monitoring Company Name: Fire Protection, Inc.
f71 - '� ' �'c
System Make:
INA. - r)- -z—
System Model: I 5(_C'V)
System Location:
Account#:
PEPBLFNs FoUND:
NA C, C(4
U1 _�(7/ /J
,,I
�7211
BREQ11ONS RMDE- -rect J, Corrected B
% &T
IA)l wu�
This certifies that this fire and life safety system has been properly inspected for reliability to cover the
items listed in this report and is consistent with the Fire Department Fire Code standards, and that
discrepancies are noted and have been reported to the building Owner/Manager for corrective action.
Signature of Tester, Phone # 425-290-9600
Testing Agency: Fire Protection, Inc.
Mailing Address: 1730 Gibson Road, Everett, WA 98204
Building Representative: (sign) X -SQGQ (print D\
3�Ll� - M
�r�t
Fire Alarm Systems Page 1 o.f,2
11111111111111111-MMMM 61111111=1 IME01=104 =1014MEW-91M
Apr 11 11 10:11a Northwestern Familtj Home 4253550101 P.3
-7
Fire Protection, Inc. Aect. #: - 5 6' Z / ( �.'
The items on the checklists below shall be inspected and tested. This list does not constitute all of the
required inspecting and testing of the fire and life safety system. Refer to the Fire Department Fire Code
for inspecting and testing requirements.
Alarm System Functionality
1 .
Trouble signal with AC power off?
XYes
0 No
2.
System operates properly on battery backup?
gYes
C] No
3.
Battery voltage (no load) volts
4.
Battery voltage.(full load) I -volts (signals operating)
5.
Charge circuit voltage volts
6.
System operates properly on standby power?
M Yes
Q No
7.
All signals operate on AC power?
'5( Yes
ED No
8.
Numbv of:initiating circuits
9.
Number of signal circuits
10.
Does alarm system meet audibility standards as accepted?
'T11 Yes
El No
11.
All circuits checked for electrical supervision? '
0 Yes
L) No
12.
All auxiliary equipment operates (elevators, fans, dampers)?
N/A
C2 Yes
C3 No
13.
Ventilation controls operate?
';X
;ZN/A
El Yes
D No
14.
Key to panel available?
Q Yes
X -No.
15.
Operating instructions at panel?
U�Yes
0 No
16.
Trouble, indicators funct! on properly?
;d Yes
C3 NG
17.
Remote Annunciator Panels function properly?
D N/A
21'Yes
Q No
18.
Elevator Call Down functions properly?
;r N/A
�.O. Yes
0 - No
19.
Test record posted at panel?
)Z Yes
0 No
20.
General alarm automatic tinfe dela; (minutes)
y -
..ET N/A
21.
Was a signal received at the Central Station monitoring company?
0 N/A
ja'Yes
0 No
22.
Other Devices (specify)
Ll Y04 j
_-El No
I - 'I
XJI�Vijef 01v? 'r -XIotal
C-A
bevice's
Nu f
r=ng
Tptaj-N� ber'%/
'j AL -
Syst e-'r:n
Units in B
e iejd
KYSUIM-Ac2p
23'.
Bells, Horns, Chimes
L1 N/A
ff Yes
�d No
24.
Voice Speakers (Voice Clarity)
-:T N/A
D Yes
Q No
25.
Smoke Detectors
0 N/A
RrYes
D No
26.
Heat Detectors
D N/A
pr Yes
0 No
27.
Duct Detectors
2.-N/A
Ll Yes
D No
28.
Sprinkler Flow Switches
J, N/A
El Yes
D No
'29.,
Sprinkler, Supervisory Switches
2r N/A
El Yes
0 No
30.
Visual Alarm Devices
a N/A
0 Yes
:1 No
31;
Manual Pull Sta tions
0 N/A
0 Yes
i:j No
32.
Annunciator(s)
Zl N/A
Yes
0 No
33.
Beam Detectors
N/A
El Yes
Q No
34.
Automatic Door Unlocks
N/A
D Yes
0 No
35.
Automatic Door Release
N/A
U Yes
Q No
36.
Fire Dampers
N/A
0 Yes
L) No
Total Number of
Total Number
Communications
Equipment
Units in Building
Units Tested
Test Results Acceptable
37.
. Phone Sets
U N/A
U Yes
L] No
38.
Phone Jacks
Yes
'>W
4
0 No
39.
Call -In Signal
0 No
Fire Alarm Systems Page 2 of 2
�GTMI M Of I 1=1 4 M
Apr 11 11 10:12a Northwestern Familtj Home 4253550101
.. p * 4 __
Emerald Tire
- Fire Sprinkler Specialists
11021 Cramer Rd. KPN - Gig HafborWA 98329
Office (253) 857-2056 - Fax (253) 857-2312 - Local 699 Contractor
AUTOMATIC SPRINKLER SYSTEMS
Inna C%vctam niar Rpnort)
21110 - F-01M LN -
Occupancy Address: 9�c&naac& 9XV-26-- OccupancyName&w ERmmel*'J�lw
Responsible Person: — Phone Number -
Building Owner:
Phone Number -
Date of Inspection: 2- (-Q Type of Inspeaion: Quarterly C3 Annual W Other
Testers Name (Please Print): %4 WA State FSCC#—Q633--I1--QkM
t
QRY SYSTEWPRE-ACTION SYSTEM:
1 . Trip test (dry trip or full flow) conducted: .................................................. Yes Ej No 0
System tripped in _seconds.
2. All flow switches, supervisory switches and ala Wlstested .................... F] No [] N/A E]
hes and aa
3. Alarm bell operates: ...................... .1 . ..... I .............................. .......... Yes 0 Noo NIA (3
4. Flow tests conducted: .................. ................................. ..................... Yes E] Noo
Flow pressure: psi -inch drain? ......... ............................ Yes 0 No
5. Systems inspected and lubricated: ................. ............... .. .................... Yes E) No [3 N/A E]
6. Air compressor refills system in 30 min s: ................ A ............... I ... Yes No [3
7. System drained and restored t rmal operation: ..................................... Yes No []
8. Were the heat actuation vices tested an pre -action and deluge system? Yes 0 NoC3 N/AC]
WET SYSTMANTI-FREEZE SYSTEM -Tested at
i . Trip test conducted: ........................................ ;':6� ...... r' ........................ No (I
Static pressure: -!CX�— psi Flow pressure: s inch drain? ........ Yes No N/A [j
2. Flow switches, supervisory switches and alarm bells tested: ..................... Yes No N/A El
3. Alarm bell operates: ............................................................................. Yes N oja N/A E]
4. Systems inspected and lubricated: .......................................................... Yes No []
S. Pressure regulating valves tested: ........................................................... Yes Ej No E] N/A DQ
ij =@j sMEM- M
Apr
11 11 10:12a
Northwestern Famil!j Home
4253550101 P.5
MOMATIC SPRINKLER SYSTEMS (can-vinuedl
General:
1,
Central Station Monitoring? ................................. .......................... I .......
Yes
No [V
Monitoring company name Z=d awl'f
2.
Location of Sprinklers
100% ......... JM Parking ......... Basement ......... Hallways ......... Other ........ 0
3.
Pumper connections and clapper valves unobstructed .......................................
Yesp
NoEj
4.
Sprinkler heads less than 50 years old .......................................... ...................
Yes
No
5.
Sprinkler coverage is acceptable ....................................................................
Yes[!o
Noo
6.
Spare sprinkler heads are available .................................................................
Yes I
No 0
7. Systems left in service .................................................................................. Yesp Noo
8. Valves are sealed or supervised ...................................................................... Ye 5 No F1
9. Signs are provided on valves ......................................................................... Yes gf No CD
10. City Static water pressure ---.Z—,Psi.
Problem,$ Fqtlnd:
3.
Cgrr-e-alons Made: DateCorrected. :2—t—P-1 Corrected By:
SIGNATURE OF TESTER:
AGENCY: -Emcn, ld Fire PHONE: 253-857-205(i
MAILINGADDRESS: 11021-0-a—mcr Boad KPN. Gig Harbor, WA 98329