2009, 04-17 Permit App: 09000995 Adult Family HomeAPPLICATION AND INSPECTION CHECKLIST - Adult Family Home
Code References: 2006 IRC Section R325 (WAC 51-51)
del S
6 2
APPLICATION NUMBER:
Applicant must complete sections 1, 2, 3, and 4. Application must be complete to be processed.
SECTION 1 - PROPERTY INFORMATION
SITE ADDRESS: -) 1 I
A
ASSESSOR'S TAX/PARCEL #: 4572. `Ir 3,ti, -5- 6 7
SECTION 2 - APPLICANT INFORMATION
PROPERTY OWNER NAME: I -k e 1 e r F ht ct N r S
LICENSEE NAME (IF oureaEml: 'C' c Ct/V1 C I U- r
DAYTIME PHONE: I S ' r7 (/a - yC( 2q
DAYTIME PHONE: SD, - rao''1 - / b/ O
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)
Zcsv,Vt. 1 k -
CDC/IAA-
it/5
�I
N5 f / 4/5 "Z r 5 I
(v(`-45
�-w
5( ,i"
Godity-
SECTION 4 — DISCLAIMER/SIGNATURE BLOCK
I certify under penalty of.perjury that he 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 person, including the undersigned, and filed against the jurisdiction, but only where such claim arises out
of the reliance of the jurisdiction, including its officers and employees, upon the accuracy of the information supplied to the jurisdiction as a part of
this application. /�
NAME/TITLE: _� / r 1 c'--- l . ink ' O%(_> %1-°-y DATE: — I7 ' 01
0 PROPERTY OWNER Ch APPLICANT 0 LICENSEE
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 0 S II NS1 0 NS2
Bedroom door is openable from the outside when locked 0
Closet doors are readily openable from the inside 0
Smoke alarm is installed in the bedroom 0
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide) 0
Sleeping room window has a maximum sill height of 44" 0
Sleeping Room #2 0 S L►f NS 1 0 NS2
Bedroom door is openable from the outside when locked 21 0
Closet doors are readily openable from the inside i/ 0
Smoke alarm is installed in the bedroom m 0
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide) VI 0
Sleeping room window has a maximum sill height of 44" a' 0
Sleeping Room #3 0 S ® NS1 0 NS2
Bedroom door is openable from the outside when locked 6j
Closet doors are readily openable from the inside 6/
Smoke alarm is installed in the bedroom m
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20• wide) El
Sleeping room window has a maximum sill height of 44"
Sleeping Room #4 0 S NSI 0 NS2
Bedroom door is openable from the outside when locked
Closet doors are readily openable from the inside lay
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" .13'
Sleeping Room #5 0 S 0 NS1 0 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) 0 0
Sleeping room window has a maximum sill height of 44" 0 0
Sleeping Room #6 0 S 0 NSI 0 NS2
Bedroom door is openable from the outside when locked 0 0
Closet doors are readily openable from the inside 0 0
Smoke alarm is installed in the bedroom 0 0
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24• high; 20^ wide) 0 0
Sleeping room window has a maximum sill height of 44" 0 0
GENERAL
Bathroom doors are openable from the outside when locked 0 0
Smoke alarms are installed on all levels of the dwelling 0 0
All smoke alarms are audible in all parts of the dwelling upon activation of a single device 0 0
Access road and water supply approved by Fire Department 0 0
YFi, NO
0000❑ 0000❑
❑ ❑
❑ ❑
❑ ❑
PASSED
INSPECTOR:
RRECTIONS REQUIRED
DATE:
0 PERMIT REQUIRED
Application and Inspection Checklist de ed by Washington Association of Building Officials (WABO), in
cooperation with Department of Social and Health Services (DSHS) for use by both departments and licensors.
NATIONWIDE INVESTING, LLC
PEOPLE HELPING PEOPLE
February 7th 2008.
To Whom it May Concern:
Buyers/Tenants Brian & Julie Clark have permission to operate an
adult family home located at 3116 S. Bowdish, Spokane, WA 99206
and to make any changes necessary to facilitate their needs.
Including permits for any alterations.
Sincerely,
Helen Eliadis
2201 Ironwood Place,
Suite 100
.:.Coeur d'Alene, Idaho
PHONE (208) 704-8159
FAX (208) 664-8084
E-MAIL Natio wdeewes&rg4,gyahoo.com
wEn SAE wiw NatenridekwestingLL.0 oom-
,