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2007, 02-08 Permit App: 07000425 Adult Home Inspect d 0IS Permit Center PERMIT NUMBER: Spode 11707 E Sprague Ave,Suite 106 /7-0(1 sM He Spokane Valley,WA 9920,6 1 PERMIT FEE: j (509)688-0036 FAX: (509)688-FJ�9 I ` / Community Development www.spokanervalley.or , \V-) ilii { it ,` 6. 1 �1 Safety InspectionAdult Family Home Permit Application Fire/Water/Vehicle Damage [f Other: SITE ADDRESS f9041 St, kJepcL.ER. ASSESSORS PARCEL NO: LEGAL DESCRIPTION: Building Owner: Contractor: Name: reg ca ci it j ch-e.J�Z L�s h n J J Name: Address: iso q S S !I Address: City: SPS ��,i'l� State:_ Zip:,octo City: State: Zip: Phone: Fax: Phone: Fax: 5'oc1 -as, , c ►i j � �i -c►-o Contractor Lic No: Exp Date: Contact Person City Business Lic.No: Name: p� ), Phone: C��J 91-D©i Describe the scope of work in detail: Cost of Project: $ CX{ b `i Pciu Ikme. Z1 **************The following MUST be complete: (write N/A if not applicable)********************** HEIGHT TO PEAK: DIMENSIONS: #OF STORIES: TOTAL HABITABLE SPACE: MAIN FLOOR TO SQ. 2ND FLOOR SQ. FTG: UNFIN BASEMENT SQ. FTG: IMPERVIOUS SURFACE FTG: AREA: FINISHED BASEMENT GARAGE SQ. FTG: DECK/COV. PATIO SQ. FTG: 30% SLOPES ON SQ. FTG: PROPERTY: #OF BEDROOMS: CONSTRUCTION TYPE: HEAT SOURCE: SEWER OR SEPTIC? The permitee verifies, acknowledges and agrees by their signature that: 1) If this permit is for construction of or on a dwelling,the dwelling is/will be served by potable water. 2) Ownership of this City of Spokane Valley Permit inure to the property owner. 3) The signatory is the property owner or has permission to represent the property owner in this transaction. 4) All construction is to be done in full compliance with the City of Spokane Valley Development Code. Referenced codes are available for review at the City of Spokane Valley Permit Center. 5) This City of Spokane Valley Permit is not a permit or approval for any violation of federal,state or local laws,codes or ordinances.6) Plans or additional information may be required to be submitted,and subsequently approved before this application can be processed. Signature /2 6Date - &-c)-7 Method of Payment: 0 Cash . Check 0 Mastercard 0 VISA Bankcard#: Expires: VIN#: Authorized Signature: REVISED 8/25/2005 APPLICATION AND INSPECTION CHECKLIST - Adult Family Home Code References: 2003 IBC 310(WAC 51-50)and 2003 IRC 110(WAC 51-51) APPLICATION NUMBER: Applicant must complete sections 1, 2, 3, and 4. Application must be complete to be processed. SECTION 1- PROPERTY INFORMATION SITE ADDRESS: ICIO LI S VE I— C ASSESSOR'S TAX/PARCEL#: - SECTION 2-APPLICANT INFORMATION PROPERTY OWNER NAME: G,-e� a pi m eche 1I; ;. fah I) DAYTIME PHONE: 1 I-2u I I LICENSEE NAME(IF DIFFERENT): AP`ph,r,j Cel.rZ.. 1.nr. DAYTIME PHONE: '31 4 11 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) 1 „zi s'gyp'' - r. IZ SIL et- A( 4.. Lill Y 1" --+ • / ex.* Sidi r SECTION 4—DISCLAIMER/SIGNATURE BLOCK I certify under penalty of perjury that the information fumished 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 this application. NAME/TITLE: _at&a�r�G DATE: CP'g-U---7 ErPROPERTY OWNER `F ) APPLICANT F LICENSEE SECTION 5-INSPECTION CHECKLIST 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 ❑ 0 SLEEPING ROOMS 0 El Sleeping Room #1 ❑ S 0 NS1 ❑ NS2 Bedroom door is openable from the outside when locked 0 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" ❑ ❑ Sleeping Room #2 0 S 0 NS1 ❑ NS2 Bedroom door is openable from the outside when locked ❑ 0 Closet doors are readily openable from the inside 0 0 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) 0 0 Sleeping room window has a maximum sill height of 44" ❑ ❑ Sleeping Room #3 ❑ S 0 NS1 ❑ NS2 Bedroom door is openable from the outside when locked 0 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) El El Sleeping room window has a maximum sill height of 44" 0 ❑ Sleeping Room #4 ❑ S 0 NS 1 ❑ 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 ❑ ❑ Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions-24"high;20"wide) ❑ El 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 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 #6 ❑ 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) El El 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 0 ❑ 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 ❑ ❑ ❑ PASSED ❑ CORRECTIONS REQUIRED ❑ 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.