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2008, 02-08 Permit App: 08000356 Adult Family HomeV) L t LL 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 ? C(9 Applicant must complete sections 1, 2, 3, and 4. Application must be complete to be processed. SECTION 1- PROPERTY INFORMATION SITE ADDRESS: / / Vi 3 e ASSESSOR'S TAX/PARCEL #: - SECTION 2 - APPLICANT INFORMATION PROPERTY OWNER NAME: /14-12 I f— ISCZ-A) A R'e-t ( -rS DAYTIME PHONE: 504 g(; `ILL.) LICENSEE NAME (IF DIFFERENT): Re_; AI D'2 is (t4 -rt' LetfACAYTIME PHONE: t:co j' gip,* L» t9 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) r Ork if 1' _+ (-f}iaNJfy —DM----- X1'445 3 t ' 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 am in the process of making an 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 attomeys' 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 application. NAME/TITLE: g PROPERTY OWNER lQt APPLICANT % LICENSEE DATE: .2/L‘Vo,$) 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 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 0 S 0 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 #3 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) Sleeping room window has a maximum sill height of 44" Sleeping Room #4 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) 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 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) 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 ❑ S ❑ NS1 0 NS2 0 PASSED YES NO ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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.