The URL can be used to link to this page

2009, 01-28 Permit App: 09000170 Adult Family HomeAPPLICATION AND INSPECTION CHECKLIST - Adult Family Home Code References: 2006 IRC Section R325 (WAC 51 -51) APPLICATION NUMBER: Applicant must complete sections 1, 2, 3, and 4. Application must be complete to be processed. (mo c,- SECTION 1 - PROPERTY INFORMATION SITE ADDRESS: I 0 9 W ASSESSOR'S TAX/PARCEL #: - PROPERTY OWNER NAME: NI lC I< Go t i ck-1 C7 / DAYTIME PHONES ) a 1 76 `i DAYTIME PHONE: LICENSEE NAME (if DIFFERENT): SECTION 3 - FLOOR PLAN A complete floor plan must include all sleeping rooms, identified by number ( #1, #2, #3 etc.) and all components for exiting, i.e. stairs, ramps, platform lifts and elevators. (Attach additional sheets if necessary) SECTION 4 — DISCLAIMER /SIGNATURE BLOCK I certify under penalty of perjury that the information furnished by me is true and correct to the best of my knowledge, and that I am requesting or I am authorized by the owner of the above premises to request inspection for the operation of an Adult Family Home at this location. I further certify that I have made application to the Department of Social and Health Services for an adult family home license and that I have also made application to the applicable jurisdiction for the appropriate license(s) to conduct such business at this location. I further agree to hold harmless the jurisdiction conducting such inspections, at my request, as to any daim (including costs, expenses, and attorneys' fees incurred in the investigation of such daim), which may be made by any person, induding the undersigned, and filed against the jurisdiction, but only where such daim arises out of the reliance of the jurisdiction, induding its officers and employ s, upon the accuracy of the information supp ied to the jurisdiction as a part of this application. NAME /TITLE: /PROPERTY OWNER APPLICANT ❑ LICENSEE DATE: SECTION 5 - INSPECTION CHECKLIST Note: Checklist to be completed by building department in the jurisdiction home will be located. Home licensed (or applying for license) on or after July 1, 2001 SLEEPING ROOMS Sleeping Room #1 ❑ S ❑ NS1 ❑ NS2 Bedroom door is openable from the outside when locked Closet doors are readily openable from the inside Smoke alarm is installed in the bedroom Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide) Sleeping room window has a maximum sill height of 44" Sleeping Room #2 ❑ S ❑ NS ❑ NS2 Bedroom door is openable from the outside when locked Closet doors are readily openable from the inside Smoke alarm is installed in the bedroom Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide) Sleeping room window has a maximum sill height of 44" Sleeping Room #3 ❑ S ❑ NS1 ❑ NS2 Bedroom door is openable from the outside when locked Closet doors are readily openable from the inside Smoke alarm is installed in the bedroom Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide) Sleeping room window has a maximum sill height of 44" Sleeping Room #4 ❑ S ❑ NS1 ❑ NS2 Bedroom door is openable from the outside when locked Closet doors are readily openable from the inside Smoke alarm is installed in the bedroom Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide) Sleeping room window has a maximum sill height of 44" Sleeping Room #5 ❑ S ❑ NS1 ❑ NS2 Bedroom door is openable from the outside when locked Closet doors are readily openable from the inside Smoke alarm is installed in the bedroom Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide) Sleeping room window has a maximum sill height of 44" Sleeping Room #6 ❑ S ❑ NS1 ❑ NS2 Bedroom door is openable from the outside when locked Closet doors are readily openable from the inside Smoke alarm is installed in the bedroom Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide) Sleeping room window has a maximum sill height of 44" GENERAL Bathroom doors are openable from the outside when locked Smoke alarms are installed on all levels of the dwelling All smoke alarms are audible in all parts of the dwelling upon activation of a single device Access road and water supply approved by Fire Department ❑ PASSED YES NO ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ CORRECTIONS REQUIRED ❑ PERMIT REQUIRED INSPECTOR: DATE: Application and Inspection Checklist developed by Washington Association of Building Officials (WABO), in cooperation with Department of Social and Health Services (DSHS) for use by both departments and licensors. W0:71 V VINDC-11N0179N V 7l OGIc 596I-V55 (605) ,xvJ VIZZ -Z9F (6o5) 'Zvottd 90266 of . 7117-710ds' -/v -wog s176 01C-31 ?IV ldCS£till 1 A 1 NIbN - NId1d 21001d c1Nn1No7 110-,0E 8 rc unxunanlmmnnImnannnt n 110-,01 d ©n0,iX101£ to n1111lpnlin 7mIlimw1 moll a IIIlm ium uttnlunxmlxtl ittitinlllllduulr!Omin!m inti W,1 L L!LJ! 11,>m11,,, 16 -,01 n0-,£ ` "V3ds 244 aid 9399RU 40021 2 2 11 �lE OIIIIINmMII1113 [11Il�unn 1111111011,1nnnumll1n1111n11an11111mun11,... C- o Q WAMIMIM 13H6 • mi 1_ 11 . , �.a � 11111 'E tl' 11x1W111111 111111IIIIIIm1111111YIM111'II I1I11IJlnlll 111 II -z a 1!Im111111111111V1111!1NII 1!!!1111111p!II!11111, 16-,11 NI1111UIImN II!!111x1111m1 JIIIII!!m111111 111111111!I11111!!UMLI111 II!lllmxnl II mfreadi Rolm i■ [ppm■ ■i rIlllllmm„ 111 4 11111(1111 itilin 1111 un!11tI rauuu!unnmunw1an11mnnunmonNL 1111 11111 IlI ununr !11121 CC • 1.. �linaanl MINI uma� a..nnmom,ol,.,,a,1 ao W.11. mrm,.n1h1.11 ,..,1m,0n111 Ade It11.1 213.1 939•r21. .10021 aw- Il IC • �I 01•011•011•011•7M111,7111, All■Iiidll•WVIMMOlvIhOW•T1111SSd11A,TY n01il11NP1L, 1111 1mC171 N\ NI1n11115{, F111A11N11\ i,\ NL11 1NI)xn11111P1ui1 I1 1N \P111f1m111 \!111111\i{511111x 19-,4 nE-,E a 11 $11 41 1 • b 1 b� a sa CC I is 'ill i� d , 111 ge111g A o� N5N110 /m ,UIN3A h10T I V 1i5 ®4- 110ji-5Nd7lodC 5961-1745 (6o5) .xvj prat -z95 (6o5) .-Tofrd 9az66 vi■1 -30?lodc env Irlooci - 5ip6 DC O 1 -JO .91• 1610r laa ex% dI) L �p q tf N L -J N.7ic -na -nVvorr Vg 1N3W3SVg - NV"ld NOI.I.VCIM104;CINV 9NIIOOd .0 -.91' / / 0-2I .6-XI .� .E -.91 n0 -.5 .0-1 . xvma8av NY Sig .0 ".i Ti 1 • E I 1 31 // ®I I • I( / VO3d9 2:61-1 a3d slslOr , �L- ,I i9- NOO I Irl a3ri33M9N3-321d ) I .� 9 ..0_,1, .6-.£I al 4-.91 C ..0-.5 ul 1 w ci !et 1.;, `w m ,, �� ICCC ) ' 4r= rs, � daa .. �__- 1..1 � 1 1 - - - -I z d o i r ry � a it X11 CAi' '1 LJ I I 1 L�J Imo° --I - --1T 1 !i11S VA.IS A4 aid sls1or ■1 L, •y� 33N1%3-36.1 N00 1=I in a3a N / 00-.4 .6-.£1 Ij ..E-•i ..O.LII .0 -.Z1 's Po r - NI I i 'NIW r 61 O ffi i ,_�� 1W <°h wa ^ Z gg A{CO+ I ,, If L L 1 J 1 — .0-.i ! 40-.41 / 4-.8Z 111 0 ti