2002, 11-21 Permit App: 02010440 Remodel Project Number: 02010440 Inv: 1 Application Date: 11/21/2002 Page 1 of 2
THIS IS NOT A PERMIT
Penalties will be assessed for commencing work without a permit
Project Information:
Permit Use: CONVERT LOWER WEST END BEDROOM TO Contact: ARMSTRONG,KIRK&MARCIE
L.C. ROOM (6 CLIENTS TYPE S) Address: 4722 S TIPAWAY ST
C-S -Z: SPOKANE,WA 99206
Setbacks: Front Left: Right: Rear: Phone: (509)927-9175
Group Name:
Site Information: Project Name:
Plat Key: 001742 Name: MYRON ESTATES#6 District: H
Parcel Number: 44042.1809 Block: Lot:
SiteAddress: 4722 S TIPAWAY ST Owner: Name: ARMSTRONG,KIRK&MARCIE
SPOKANE,WA 99206 Address: 4722 S TIPAWAY ST
Location::SPO SPOKANE,WA 99206
Zoning: UNKN Unknown
Water District: Hold: ❑
Area: 0 Sq Ft Width: 100 Depth: 150 Right Of Way(ft): 50
Nbr of Bldgs: 1 Nbr of Dwellings: 1
Review Information:
Review
t
Plan Review Released By: �' h + ' �►
Permits: .
Operator: CKF Printed By: CKF Print Date: 11/21/2002
Project Number: 02010440 Inv: 1 Application Date: 11/21/2002 Page 2 of 2
THIS IS NOT A PERMIT
Penalties will be assessed for commencing work without a permit
Building Permit
Contractor: OWNER Firm: OWNER
Phone:
Building Characteristics
Const Category: Remodel Group: Type:
Nbr Of Dwellings: Occupant Load: Building Height: Stories:
Bldg W x D: x Building Sq Ft: Sprinklers: ❑
Req Parking: Handicap Parking: Critical Materials: ❑
This Application: Total Project:
Description Grp Type Notes Sq Ft Valuation Sq Ft Valuation
RESIDENCE R-3 VN REMODEL 0 $1,000.00 0 $1,000.00
Totals: 0 $1,000.00 0 $1,000.00
Item Description Units Unit Desc Fee Amount
RESIDENTIAL VALUATION 1 Y OR BLANK $35.75
STATE SURCHARGE 1 Y OR BLANK $4.50
RESIDENTIAL SURCHARGE 1 Y OR BLANK $7.87
Permit Total Fees: $48.12
Notes
SITE IS LICENSED FOR 6 CLIENTS -TYPE S -LEVEL I
Payment Summary:
Permit Type Fee Amount Invoice Amount Amount Paid Amount Owing
Building Permit $48.12 $48.12 $0.00 $48.12
$48.12 $48.12 $0.00 $48.12
Disclaimer:
Submittal of this application certifies the owner(or person(s)authorized by the owner)has both examined and finds the information
contained within to be true and correct,and agrees that all provisions of laws and/or regulations governing this type of work will be
complied with. Subsequent issuance of a permit shall not be construed to be a permit for,or an approval of,any violation of any of the
provisions of the code or of any other state or local laws or ordinances.
Signature:
Operator: CKF Printed By: CKF Print Date: 11/21/2002
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°°"r•°r.tiw°j°`''''d REQUEST FOR INSPECTION- Adult Family Home
APPLICATION NUMBER:
Applicant must complete sections 1, 2, 3, and 4. Application must be complete to be processed.
SECTION 1`-PROPERTY INFORMATION "
SITE ADDRESS: 4`J 722.. Sr tji / 5 ASSESSOR'S TAX/PARCEL#: -
"'SECTION 2 'APPLICANT INFORMATION
PROPERTY OWNER NAME: Kr f�[T ' 57-464& DAYTIME PHONE: 0-7`R/-75,..1)/0 —// 0
LICENSEE NAME pr.DIFFERENT): [%te-K (V 1tF i 4'tf Tizi2G DAYTIME PHONE: ��-917
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)
`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 authorized by
the owner of the above premises to request inspection for and operate an Adult Family Home at this location. I further certify that I have made
application to the Department of Social and Health Services and the 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 . es out of the eliance of the jurisdiction,including its officers and employees, upon the accuracy of the
information supplied to the jurisdiction . part of this '.plication.
S
NAME/TTTLE: "' �' 4
DATE: C s �r
PROPERTY OWNER APPLICANT 4 ICEN EE
x .; v _. rSECTIOlYS INSPECTION CHECKLIST
7NO
Home licensed (or applying for license) on or after July 1, 2001 ❑
SLEEPING ROOMS CI CIf
Sleeping Room #1 ,,�1 S ❑ NSI ❑ NS2
Bedroom door is openable from the outside when locked / ❑
Closet doors are readily openable from the insideD
Smoke alarm is installed in the bedroom Ca'
D
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' D
Sleeping Room #2 /S D NSI D NS2
Bedroom door is openable from the outside when locked D
Closet doors are readily openable from the inside ‘ D
Smoke alarm is installed in the bedroom K D
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"/ '£ D
Sleeping Room #3 jl S D NS1 ❑ NS2
Bedroom door is openable from the outside when locked D
Closet doors are readily openable from the inside xf ❑
Smoke alarm is installed in the bedroom ram D
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions-24"high;20"wide) 2( ❑
Sleeping room window has a maximum sill height of 44" ',{' D
Sleeping Room #4 S ❑ NSI ❑ NS2
Bedroom door is openable from the outside when lock d
Closet doors are readily openable from the inside � CI D
Smoke alarm is installed in the bedroom Z ❑
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions-24"high; 20"wide) Z. ❑
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" ❑ Cl
Sleeping Room #6 ❑ S ❑ NSI D NS2
Bedroom door is openable from the outside when locked D ❑
Closet doors are readily openable from the inside ❑ 0
Smoke alarm is installed in the bedroom ❑ D
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" ❑ D
GENERAL
Bathroom doors are openable from the outside when locked �?:r. ❑
Smoke alarms are installed on all levels of the dwelling ...2r- D
All smoke alarms are audible in all parts of the dwelling upon activation of a single device ,.,B' ❑
Access road and water supply approved by Fire Department 0
Cl PASSED ❑ CORRECTIONS REQUIRED Cl PERMIT REQUIRED
INSPECTOR: _ DATE:
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