2009, 02-23 Permit App: 09000426 Adult Family HomeAPPLICATION AND INSPECTION CHECKLIST - Adult Family Home
Code References: 2006 IRC Section R325 (WAC 51-51)
APPLICA7ION NUMBER:
Applicant must complete sections 1, 2, 3, and 4. Application must be complete to be processed. 1:�Q/)n
SITE ADDRESS: ASSESSOR'S TAx/PARCEL #:
SECTION• •
PROPERTY OWNER NAME: XL . DAYTIME PHONE:
LICENSEE NAME (IF DIFFERENT): i t ✓ l DAYTIME PHONE: ,<TL
SECTION• •
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)
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 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 be made by any person incl ing the undersigned, and filed against the jurisdiction, but only where such claim arises out
of the reliance of a juri "on, including its ced ployees, uaccuracy of the information supplied to the jurisdiction as a part of
this application. C�
NAME/TITLE: DATE: —�e�
PROPERTY O ER 11 APPLICAN LICENSEE
SECTION INSPECTION
Note: Checklist to be completed by building department in the jurisdiction home will be located.
YES
NO
Home licensed (or applying for license) on or after July 1, 2001
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SLEEPING ROOMS
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Sleeping Room #1 ❑ S ❑ NSI ❑ NS2
Bedroom door is openable from the outside when locked
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❑
Closet doors are readily openable from the inside
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Smoke alarm is installed in the bedroom
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Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide)
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Sleeping room window has a maximum sill height of 44"
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Sleeping Room #2 ❑ S ❑ NSI ❑ 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 ❑ S ❑ NSI ❑ 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 ❑ S ❑ NSI ❑ 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 ❑ NSI ❑ 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 ❑ S ❑ NSI ❑ NS2
Bedroom door is openabie 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
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Smoke alarms are installed on all levels of the dwelling
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All smoke alarms are audible in all parts of the dwelling upon activation of a single device
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Access road and water supply approved by Fire Department
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❑ PASSED ❑ CORRECTIONS REQUIRED ❑ PERMIT REQUIRED
INSPECTOR: DATE:
Application and Inspection Cheddist 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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