7500 212TH ST SW STE 105 (2) - 5pgs_Redacted4III IIII I 75 0 0 A r ,U J �. ( 0 �j 'FIRE PREVENTION
INSPECTION REPORT
Sr,Oerisx� Serving tsr�er, Ca�morids,id 12425 Meridian Ave S ❑ EDMONDs
Fl� Mountlake Terrace 4. —Everett, WA 98208 ❑ BRIER
Phone (425) 551-1200 ❑ MOUNTLAKE TERRACE
❑UNINCORPORATED
DISTR
www.FireDistrictl.org Fax (425) 551-1272
FREQUENCY STATIO & SHIFT
LOCATION: 7500 212 th .Street SW Suite 105 98026 2016 16-�
BUSINESS NAME: Start Case, MSW PhD PHONE: 4257755678 SCHEDULED Dec 2016
DATE DUE
MAILING UFIR / 593
ADDRESS: 7500 212th Street SW, Suite 105, Edmonds, WA 98026
BUSINESS OWNER:
HOME PHONE:
EMERGENCY-1: HOME PHONE:
CURRENT YES No
KEY ACCESS-2: HOME PHONE: CITY
EMAIL: BUSINESS 10 ❑
LICENSE
PERSON CONTACTED: INITIAL INSPECTION DATE
NAME OF INSPECTOR: oeiu-vel-l�IRE SYSTEMS:
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Date Last Serviced:
HAZARDS FOZ7LOCATIONS /COMMUNICATIONS
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[AGREE [AGREE TO CORRECTTHE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1st RE -INSPECTION
2nd RE -INSPECTION
' FINAL RE -INSPECTION
EXTENSION VIOLATIONS
DATE DUE:
DATE DUE:
GRANTED TO: ;DATE DUE: CITED:
PERSON
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LETTER NEEDED ❑ ❑
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YES NO
YES NO
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1FIRE PREVENTION
SIVOIIOMISH CO.Serving Brier; Edmonds 12425 Meridian Ave S INSPECTION REPORT
FIREMorrrrtlpke Terrace,pnd Everett, WA 98208 ❑BRIER S
❑ BRIER
the Town of Wobdwdy Phone (425) 5514200 ❑ WOODWAY
DISTRtf,O UNINCORPORATED
LAKE TERRACE
www FireDistrictl. org Fax (425) 551-1272 w"= ❑UNINCORPORATED
FREQUENCY STATION & SHIFT
LOCATION: 7500 212th Street Sw 105 731 16 O
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BUSINESS NAME: ���+.i PHONE: ��'� SCHEDULED
DATE DUE � 12l01111
MAILING 7500 212th St SW #105 uFIR ► 593 1 E157
ADDRESS: Edmonds 98026
BUSINESS OWNER:
HOME PHONE:
ACTIVE
'
EMERGENCY-1: Case, Stan
HOME PHONE: 425771/171
CURRENT
KEY ACCESS-2:
HOME PHONE:
CITY YES NO
BUSINESS
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PERSON CONTACTED: L—
INITIAL I
iSPEITION DATE
NAME OF INSPECTOR: I�
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ANNUAL
HAZARD$ FOUND AND LOCATIONS / COMMUNICATIONS
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I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1st RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE. r
EXTENSION
GRANTED TO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
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INSPECTOR:
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INSPECTOR: 4=
INSPECTOR:
2
DATE:
DATE: `
VIOLATIONS
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DATE:
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PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2
6
2
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DATE:
CODE
SECTION:
5
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RETURN RECEIPT
RECEIVED
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DATE:
DISPOSITION:
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LETTER NEEDED ❑ YES ❑ NO
LETTER NEEDED ❑ YES ❑ NO
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FIRE DEPARTMENT COPY
CITY OF EDMONDS
BUSINESS LICENSE APPLICATION - COMMERCIAL
FEE: $125.00
CITY CLERK'S OFFICE, BUSINESS LICENSE DIVISION
121 5T" AVENUE NORTH, EDMONDS, WA 98020 PHONE 425.775.2525
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Building
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❑
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Planning
❑
Police
OFFICE USE ONLY
BL#
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Customer #
SIC I
Year
Class
SHD
I Date Paid
I TR#
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Deleted
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. License expires December 31" each year. Renewal
must be submitted prior to January 318' to avoid late fees.
BUSINESS NAME John A. DeNinno, Ph.D.
BUSINESS ADDRESS 7500 212th St. SW 105 Edmonds, WA 98026
Street Suite # City, State, Zip Code
MAILING ADDRESS Same as above
Street or PO Box # Suite # City, State, Zip Code
BUSINESS PHONE( 206 1 363-4205 WA STATE TAX ID # (UBI) 1 6 0 1 0 2 1 8 1 9 9 1 3
BUSINESS E-MAIL DrJohn@JohnDeNinno.com BUSINESS WEBSITE WWw.johndeninno.COm
BUSINESS OWNER / MAIN CONTACT John A. DeNinno 1206 1 363-4205
Name Phone Number
PROPERTY OWNER Clay Enterprizes ( 425 ) 776-1234
Name Phone Number
EMERGENCY NOTIFICATION (For Premise Access in Emergency):
Clay Enterprizes , 425 1 776-1234
Last Name Fast Name MI Phone Number
I 1
Last Name Fast Name MI Phone Number
NATURE OF BUSINESS (Provide a Detailed Description of Business Activities, Products s Services): Psychologist
SPACE ALTERATIONS TO BE MADE: YES -NO X DESCRIPTION
PREVIOUS BUSINESS AT THIS ADDRESS Psychologist
NUMBER OF EMPLOYEES 0 SQUARE FOOTAGE OF BUSINESS SPACE 150 salt
TYPE OF BUSINESS — PLEASE CHECK APPROPRIATE CATEGORY:
❑ CONSTRUCTION
❑ FINANCE, INSURANCE, REAL ESTATE
❑ LANDSCAPE, HORTICULTURAL
❑ MANUFACTURING
❑ NON-PROFIT
❑ RETAIL
❑ SECONDHAND DEALER
IX SERVICES
❑ WHOLESALE
❑ OTHER
PROPOSED OPENING DATE: 01/01Q017
BUSINESS HOURS: 11 am-7pm
DAYS OPEN:
❑ SUNDAY Q(WEDNESDAY
❑ MONDAY ❑ THURSDAY
q(TUESDAY ❑ FRIDAY
❑ SATURDAY
AMUSEMENT DEVICES ON PREMISES? YES NO X IF YES, TOTAL NUMBER LIQUOR SOLD ON PREMISES? YES NO X
GAMBLING? YES_ NO X CIGARETTES SOLD ON PREMISES? YES NOS_
FLAMMABLE OR HAZARDOUS MATERIALS USED OR STORED? YES NO X IF YES, PLEASE PROVIDE A LIST OF MATERIALS AND QUANTITIES:
PARKING SPACES ON SITE: TOTAL SPACES 80 ACCESSIBLE SPACES FOR HANDICAP PARKING 4
DOES THE BUSINESS CONTAIN AN ENTRANCE ACCESSIBLE TO PERSONS WITH DISABILITIES? YES—X NO
APPLICANT
NAME John A. DeNinno Ph.D. 1.d
Printed NON
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TITLE sole proprietor D .E 12/301i�6
NAME DSNInm John A.
LAST FIRST MIMLF NITIAI.
ADDRESS 7500212th St SW 106 Edwards, WA 98026
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