2009, 09-26 Permit App: 09002633 Adult Family HomeBY:
APPLICATION AND INSPECTION CHECKLIST - Adult Family Home
Code References: 2006 IRC Section R325 (WAC 51-51)
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APPLICATION NUMBER:
, AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED
SITE ADDRESS:
SECTION 1 - PROPERTY INFORMATION
PROPERTY OWNER NAME:
LICENSEE NAME (IF DIFFERENT):
ASSESSOR'S TAX/PARCEL# :
SECTION 2 - APPLICANT INFORMATION
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DAYTIME PHONE:
Ilvr--/DAYTIME PHONE:
SECTION 3 — FLOOR PLAN
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APPLICANT MUST DRAW A COMPLETE FLOOR PLAN ON THIS FORM. PLEASE INCLUDE ALL SLEEPING ROOMS (BEDROOMS).
**ON MI5 DRAWING, THE BUILDING INSPECTOR MUST THEN IDENTIFY WHICH ROOM IS SLEEPING ROOM #1, 2, 3, 4, 5, AND 6 AND
LABEL ALL COMPONENTS FOR EXITING i.e. STAIRS, RAMPS, PLATFORM LIFTS & ELEVATORS. (USE BACK OF THIS PAPER IF YOU NEED MORE ROOM)
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SECTION 4 — DISCLAIMER/SIGNATURE BLOCK
1 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 claim (including costs, expenses, and attorneys' fees incurred in the investigation of such claim),
which may be made by any pers•- n. ding the -. rsign; d, . fi d against the jurisdiction, but only where such claim arises out of the reliance of
the jurisdiction, including i d -mplo es, upon t .cc .cy of the information supplied to the jurisdiction as a part of this application.
NAME/TITLE:
0 PROPERTY OWNER ❑ APPLICANT ❑ LI(,
DATE:
8/1/09
NAME OF AFH:
SECTION 5 MUST BE COMPLETED BY THE BUILDING DEPARTMENT IN THE JURISDICTION THE HOME W ILL BE LOCATED.
PLEASE CHECK ALL APPLICABLE BOXES. PLEASE ALSO INDICATE ON THE FLOOR PLAN DRAWN BY APPLICANT:
WHICH BEDROOM IS #1, 2, 3, 4, 5, oR 6 AND THE CLASSIFICATION CODE: S, NSI, OR NS2 (TO MATCH THE LIST BELOW )
SECTION 5 - BUILDING INSPECTOR'S INSPECTION CHECKLIST
R325.3 SLEEPING Room CLASSIFICATION. Each sleeping room in an adult family home shall be classified as:
Type S - where the only means of egress contains stairs to evacuate.
Type NS1 -where one means of egress does not have stairs to evacuate.
Type NS2 -where two means of egress do not have stairs to evacuate.
SLEEPING ROOMS
Sleeping Room #1 , • Type Si • Type NS1 • Type NS2
YES
NO
Closet doors are readily openable from the inside YES • NO • Smoke alarm is installed in the bedroom
•
•
Bedroom door is easily and quickly openable from the outside when locked
•
•
Sleeping room window has minimum dimensions at least 24" high; at least 20" wide —(NET OPEN -ABLE AREA OF 5.7 sF **)
•
•
**EXCEPT PER R310.1.1: AT -GRADE ESCAPE WINDOWS — (MAY HAVE NET CLEAR OPENING 5 SF )
Sleeping room window has a maximum sill height of 44" above floor; no steps under window permitted
•
•
Sleeping Room #2 I • Type S I ■ Type NS1 ■ Type NS2
YES
NO
Closet door/s are readily openable from the inside y ■ NO ❑ Smoke alarm is installed in the bedroom
•
•
Bedroom door is easily and quickly openable from the outside when locked
•
•
Sleeping room window has minimum dimensions at least 24" high; at least 20" wide —(NET OPEN-ABLEAREA OF 5.7 SF **)
•
•
**EXCEPT PER R310.1.1: AT -GRADE ESCAPE WINDOWS — (MAY HAVE NET CLEAR OPENING 5 SF )
Sleeping room window has a maximum sill height of 44" above floor, no steps under window permitted
•
•
Sleeping Room #3 I ■ Type S I • Type NS1 ■ Type NS2
YES
NO
Closet door/s are readily openable from the inside YEs ■ NO • Smoke alarm is installed in the bedroom
•
•
Bedroom door is easily and quickly openable from the outside when locked
•
•
Sleeping room window has minimum dimensions at least 24" high; at least 20" wide —(NEI OPEN-IBLEAREA OF 5.7 SF **)
•
•
**EXCEPT PER R310.1.1: AT -GRADE ESCAPE WINDOWS — (MAY HAVE NET CLEAR OPENING 5 SF )
Sleeping room window has a maximum sill height of 44" above floor; no steps under window permitted
•
•
Sleeping Room #4 I • Type S I • Type NS1 ■ Type NS2
YES
NO
Closet door/s are readily openable from the inside y ■ NO • Smoke alarm is installed in the bedroom
•
•
Bedroom door is easily and quickly openable from the outside when locked
•
•
Sleeping room window has minimum dimensions at least 24" high; at least 20" wide-(NETOPEN-ABLEAREA OF5.7SF **)
•
•
**EXCEPT PER R310.1.1: AT -GRADE ESCAPE WINDOWS — (MAY HAVE NET CLEAR OPENING 5 SF )
Sleeping room window has a maximum sill height of 44" above floor; no steps under window permitted
•
•
Sleeping Room #5 I ■ Type S I • Type NS1 • Type NS2
YES
NO
Closet door/s are readily openable from the inside y ■ NO ■ Smoke alarm is installed in the bedroom
•
•
Bedroom door is easily and quickly openable from the outside when locked
•
•
Sleeping room window has minimum dimensions at least 24" high; at least 20" wide -(NET OPEN-ABLEAREA 0F5.7 SF **)
•
•
**EXCEPT PER R310.1.1: AT -GRADE ESCAPE WINDOWS — (MAY HAVE NET CLEAR OPENING 5 SF )
Sleeping room window has a maximum sill height of 44" above floor; no steps under window permitted
•
•
Sleeping Room #6 I ■ Type S I ■ Type NS1 ■ Type NS2
YES
NO
Closet door/s are readily openable from the inside YEs • NO ■ Smoke alarm is installed in the bedroom
•
•
Bedroom door is easily and quickly openable from the outside when locked
•
•
Sleeping room window has minimum dimensions at least 24" high; at least 20" wide —(NET OPEN-4BLEAREA 0F5.7 SF **)
•
In
**EXCEPT PER R310.1.1: AT -GRADE ESCAPE WINDOWS — (MAY HAVE NET CLEAR OPENING 5 SF )
Sleeping room window has a maximum sill height of 44" above floor; no steps under window permitted
•
•
GENERAL
Bathroom doors are easily and quickly openable from the outside when locked
Smoke alarms are installed on all levels of the dwelling, in each bedroom and common areas
Any smoke alarm must be audible throughout the home when activated.
Access road and water supply meet local fire jurisdictional requirements
8/1/09
NO
0
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Inside Ramp
YES
NO
R311.6.1 Maximum Slope one unit verlical in twelve units horizontal (8.3% dope).
0
0
R311.6.2 Landing Requirements: min. 3X3 foot landing at top/bottom, where doors open onto
ramps, and where ramp changes ciirections.
Fl
[]
•
YES
R311.6.3 Handrails required (on both sides af ramp: per state |icelicensingrequirementrequirementWAC 3a8-7d-1U7]D).
0
0
NO
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YES
R311.6.1 Maximum Slope one unit vertical in twelve units horizontal (8.396 slope).
N0
0
R311.6'2 Landing Requirements: min. 3X3 foot landing at top/bottom, where doors open onto
ramps, and where ramp changes directions.
0
0
R311'6.3 Handrails required (on both sides of ramp: per state Iicensinq requirement WAC 388-
0
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**Guards below are depicted vertically as an example only.
Less than 4"
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Guard36" min
zxzmin
landing ===
r
min
Handrail both sides
»r -3s'
1:12 maslope
8.3%
3'v3'min
landing
ADULT FAMILY ANE RAMP
per 9006 IRC
Wk ST' AMEKCk/E\TS
+.ALL RAMPS REQUIRE E|LDkG- P,9M|T*
R311 Means of Egress
YES
NO
R311.4.ZDoor Type and Size: Side -hinged not Iess than 3 feet in width and 6 feet 8 inches in height.
NN
Fl
R311.4.4 Type of lock or latch: readily openable from the side from which egress is to be made
without the use of a key or special knowledge or effort.
Fl
Fl
R311.5 Stairways
YES
NO
R311.5.3.1 Riser Height: Max riser height shall 6e73/4inches (8inches instructures built prior hoJuly 1.2OO4)
NN
NN
R311.5.3.2 Tread Depth: Min. tread depth shall be 10 inches. (Oinches instructures built prior toJuly 1.2OO4)
NN
0N
R311.5.6 *andrai|s required on both sides of one riser or more (per state ticensinq requirement WAC 388-76-10730)
0
[]
Grab Bars in Bathrooms
YES
NO
WAC 388-76'10730 The AFH must install and securely fasten grab bars (not suction cup style) to meet
the needs of residents in:
[]
[]
Bathing facilities such as tubs and showers; and
0
0
On both sides of the toilet (if structurally not feasible use type that affix to toilet seat)
0
0
AGM Swimming Pool, Spa Hot Tub
YES
NO
AG105 Must be surrounded by a barrier that is 48 inches high, may have doors and or gates that
must have audible alarms when opened.
0
0
AG105.5 EXCEPTION: 3paa or hot tubs with a safety cover which complies with ASTM F 1346
0
0
0 PASSED
0 CORRECTIONS REQUIRED
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[l PERMIT REQUIRED
INSPECTOR S ADDRESS: PHONE:
Application and Inspection Checklist developed by Wahin m Association of Building Officials (WABO),
in cooperation with Department of Social and Health Services (DSHS) for use by both departments and licensors.
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