2009, 07-30 Permit App: 09002340 Adult Family HomeAPPLICATION AND INSPECTION CHECKLIST - Adult Family Home
Code References: 2006 IRC Section R325 (WAC 51-51)
APPLICATION NUMBER:
9 .9340
SECTIONS 1, 2, 3, AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED
SECTION i PROPERTY INFORMATION-
SITE
NFORMATION
SITE ADDRESS: .3 //i' S: Sap ( :s L.
ASSESSOR'S TAX/PARCEL#:9s1
SE ION 2-7 APPLIC N ` OR A O `..
PROPERTY OWNER NAME: AIP Le- . I/ r r{ JCS
LICENSEE NAME (IF DIFFERS(): 'T7 a m C /Ge—CL-
DAYTIME PHONE: l ".?"O " 4 g".7'4f
DAYTIME PHONE: SCY7-/C/C
SECTION=3,- FLOOR PLAN.
APPLICANT MUST DRAW A COMPLETE FLOOR PLAN ON THIS FORM. PLEASE INCLUDE ALL SLEEPING ROOMS (BEDROOMS).
**ON THIS 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)
RECEIVED BY
CITY OF SPOKANE VALLEY
,JUL 3 0 2009
13?
E IIT CENTER
"' .SECTION 4 . DISCLAIMER%SIGNATUREI.BLOCK4:V*
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. 1 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:
(irfC +Ct,a1 C lCz (1'
0 PROPERTY OWNER 0 APPLICANT
x. LICENSEE
DATE:
A U) 30 0c
811109
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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, on 6 AND THE CLASSIFICATION CODE: S, NSI, OR NS2 (TO MATCH THE LIST BELOW )
SECTION S -BUILDING INSPECTOR'S INSPECTION{HECKLIST.:,`„
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.
PING ROOMS
Sleeping Room #1 I
• Type 5_I El Type NS1
• Type NS2
YES
;, ■
NO
,.' ■ "r
in'the;bedroorn
Closet doorls are readily openable from the inside YES
❑ NO ■ ,•" .Smoke alarm is installed
Bedroom door is easily and quickly openable from the
outside when locked
•
•
Sleeping room window has minimum dimensions at least
"EXCEPT PER
24" high; at least 20" wide -(NET OPEN -ABLE AREA OF 5.7 SF ")
•
•
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
•
•
, _Sleepmg_Room #2. ;I'.':;•
_Type 51. I gl_,Type NS1 .
• `Type NS2.,`
`YES
.NO:
Closet door/s are readilyopenable from the=inside I.E.
■NO ■ Smoke alarm is installed in the bedroom
0
•
Bedroom door is easily and quickly openable from
outside when locked .._ _ _ ;� , -
■
+ El
Sleeping room window has minimum dimensions at least
' ` "EXCEPT PER
24 high; at least 20" wide ti (NET OPEN -ABLE AREA ,OF 57 sF )
! ■
■
R310.1.1: AT -GRADE ESCAPE WINDOWS (MAY HAVE NET CLEAR OPENING 5 SF) I,
Sleeping room window has a maximum sill height of 44" above
floor; no steps under window permitted _-
in ':
-r ®
.;:. IISleeping
Room #3
• Type I S I 13 Type NS1
e
• Type NS2
YES
NO
Closet doorls are readilyopenable from the inside yEs
• NO • 'Smoke alarm Is installed (o the bedroom
„ ®
■,
Bedroom door is easily and quickly openable from the
outside when locked
•
•
Sleeping room window has minimum dimensions at least
`"EXCEPT PER
24" high; at least 20" wide -(NET OPEN -ABLE AREA OF 5.7 SF **)
•
•
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 5,` -. _,T111,0.1,11,',."4,11 .1.1-wie NS2 t
';YES
0
■
.,;
• , `NO '. • Smoke alarm is installed in the bedroom
ii Closet door/s are readilyopenable from theinside '(ES,
i. Bedroom door is.easily and quickly openable from the
outside when locked .: '
.a.®
1
Sleeping room window has minimum dimensions at least
w, `s' " "EXCEPT PER
24 high ;'-at teast20" wide (NETOPENABLEAREA ORS.? BF )
t le
`.1
R310 1.1. AT7GR>DE ESCAPE WINDOWS 41AY HAVENET_C1FAR OPENING 5 SF) �t
Indow has a maximum sIllof
=Sleeping room w r sillheightloor;
44" above f no steps, under window
permitted"'
� g
•
Sleeping Room #5
I • Type S I • Type NS1
• Type NS2
YES
NO
Closet doorls are readilyopenable from the inside VES
0 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
"EXCEPT PER
24" high; at least 20" wide-(NEHOPEN-ABLEAREA OF 5.1 SF")
•
•
R310.1.1' AT -GRACE ESCAPE WINDOWS -(MAY HAVE NET CLEAR OPENING 5 5F )
Sleeping room window has a maximum sill height of
44° above floor; no steps under window permitted
•
•
"; Sleeping;:Room 46 r t"
I . ,. • .:Type. 5 ,I: • 'Type.NS1
■. Type NS2 ,
YES
0
'.-:..NO.
•
in the bedroom
Closet door/s areteaddyopenable from the inside VES
• NO, • Smoke alarm is installed
Bedroom door, is'easily and quickly openablefrom the
outside when locked . ,, ;;
■
II
Sleeping room window has minimum dimensions ar least
.•;.
',`"EXCEPT PERR3101.1:
24"high; at least 20" wide (NETOPE.V-ABLEABEA OF 5.7 eF )
` I
® ?y
: .
AT -GRADE ESCAPE WINDOWS (MAY HAVENET CLEAR OPENING SSE)
GR,.. HAVE
Sleeping,roem window,has a maximum sill height of
44" above floor; no steps under window per`rnitted s
r ®
1,rr
YES NO
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
•
•
811(09
R311.6 Ramps
Inside Ramp
R311.6.1 Maximum Slope one unit vertical in twelve units horizontal (8.3% slope).
R311.6.2 Landing Requirements: min. 3X3 foot landing at top/bottom, where doors open onto
ramps, and where ramp changes directions.
R311.6.3 Handrails required (on both sides of ramp: per state licensing requirement WAC 388-76-10730).
Outside Ramp
R311.6.1 Maximum Slope one unit vertical:in twelve units horizontal (8.3% slope) ,.;
R311:6 2 Landing Requirements: 3X3 foot landing at top/bottom where doors openionto;ti
ramps, and whereramp changes directions..
R311.6.3 Handrails required. (on both sides oframp: per state Iicensinq requirement WAC 388-76-10730
*Guards below are depicted vertically as:an'example only. -27.!..._--;
Less than 4"
Guard
36" min
Handrail both sides
34" - 36"
' x 3' min
landing
min '
1:12 max slope
8.3%
ADULT FAMILY HOME RAMP
per 2006 IRO Ith 7i1A. ST. AMENDMENTS
"ALL RAMPS REQUIRE A BUILDING PERMIT"
3' x 3' min
landing
3'
min
R311 Means of Egress
YES
NO
R311.4.2 Door Type and Size: Side -hinged not less than 3 feet in width and 6 feet 8 inches in height.
•
•
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.
•
•
R31i5'Stairways .. '.^ t'ia.k . .,- .. si:..t7. >V :
6 YES'.
-NO'
.'F(.31:1:5: -3:t Riser: Height: Max riser height shall be 73/4 inches:-, 8 inches in structures built nor t`o Ji I 1 2004
l8 `.
"- ®-.'�.
8311.5.3.2 Tread. Depth: Min tread depth shill b'e.10 inches: (9 inches instructuresbuilt pnortoJuly 1 '204)!L
:; ■
`:1®
8311.5.6 Handrails required on both'sides of one'nser or more (per state licensing requirement WAC 388-76-10730)
: ' ■
NI
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
■
■
On both sides of the toilet (if structurally not feasible use type that affix to toilet seat)
•
•
:AG101 Swimming Pool; Spa,HotTub . ` "' r ,` . ,,, s,:
;' YES
)3G105Must be, surrounded,,by a barrier that is•48 inches' high; may have doors and or gates that
must have audibl " ' en
le'alarms when opened .,
AG105:5 EXCEPTION: Spas"or hot tubs with a`safety cover which complies with ASTM Fi1346.' < :
.. ®'
'^i ®
0 PASSED
0 CORRECTIONS REQUIRED
TNcnrnoD'S SIGNATIIDF•
INSPECTOR'S ADDRESS:
0 PERMIT REQUIRED
nATF•
PHONE:
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.
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