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2008, 03-20 Permit App: 08001005 Adult Home Inspect-t APPLICATION AND INSPECTION CHECKLIST - Adult Family Home Code References: 2003 IBC 310 (WAC 51-50) and 2003 IRC 110 (WAC 51-51) APPLICATION NUMBER: j - / 00 S — 4.7/7 Applicant must complete sections 1, 2, 3, and 4. Application must be complete to be processed. SECTION 1'- PROPERTY INFORMATION- 1%22- NFORMATION SITE ADDRESS: 1%22- S �L1lutu ASSESSOR'S TAX/PARCEL #: - SECTION '2 -'APPLICANT INFORMATION <. PROPERTY OWNER NAME: VAe tUrM '. e V- -e LICENSEE NAME (IF DIFFERENT): -PC WA.- berrA til SECTION S - FLOOR; PLAN DAYTIME PHONE: 5047 S% DAYTIME PHONE: 6 of- 4' q g -9/ 6q 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) 1 ( \1 C..loSe- 3 I_ 1 J 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 locabon. I further certify that I am in the pmrres of making an application to the Department of Soda! and Health Services for an adult family home license and that I have also made application to the applicable jurisdiction for the appropnate 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 sad] daim), which may be -. - by any person, induding the undersigned, and filed against the junsdiction, but only where such daim arises sut of the reliance of the - risdi. . on, • uding its officers and employees, upon the accuracy of the information supplied to the jurisdiction as a part of this application. NAME/TITLE: V PROPERTY OWNER 0 PPLICANT 0 LICENSEE DATE: 2D-70 --0(17 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 0 NS1 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 Sleeping Room #2 ❑ S 0 NS1 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 ❑ Sleeping Room #3 0 S ❑ 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 Sleeping Room #4 0 S 0 NSI ❑ 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 #5 0 S 0 NS1 0 NS2 Bedroom door is openable from the outside when locked 0 Closet doors are readily openable from the inside ❑ 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" ❑ 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 YES NO ❑ ❑ ❑ ❑ 0000❑ 0000❑ 0 PASSED 0 CORRECTIONS REQUIRED 0 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.