2011, 10-20 Permit App: 11003348 Adult Home Inspect .
t APPLICATION AND INSPECTION CHECKLIST- Adult Family Home
Cade References: 2006 IRC Section R325(WAC 51-51)
APPLICATION NUMBER: i j—'S',"►1
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SECTIONS 1,2,3,AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED 1
SECTION 1 - PROPERTY INFORMATION
SDE ADDRESS: it/q/f ' ISSESSORS 1 TAXIPARCELo:_ so 3\r_31��
V /, �S�ECTION 2 - APPLICANT INFORMATION j�j /�
PROPERTY OWNER NAME: l'� S 1 hei �d C� ���^ -- DAYTIME PHONE: "//��3�'[ -/�l Vp.�
LICENSEE NAME tip D E : 5Irn' • l Co /Yt- ( 1 DAYTIME PHONE:SD { -pi-730
SECTION 3— FLOOR PLAN
APPLICANT MUST DRAW A COMPLETE FLOOR PLAN ON THIS FORM. PLEASE INCLUDE ALL SLEEPING ROOMS(BEDROOMS).
**ON THIS DRAWING.THE BUILDING INSPECTOR MUST THEN IDENTIFY WHICH ROOM IS SLEEPING ROOM#1,2,3.4.5.AND 6 AND
LABEL ALL COMPONENTS FOR EXITING i.e.STAIRS,RAMPS.PLATFORM LIFTS&ELEVATORS,(Use MO(OF THIS PAPER IF YOU NEED MORE ROOM)
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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
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 licenses) 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 arises out of the reliance of
the jurisdiction,including its officers and employees,upon curacy of the information supplied to the jurisdiction as part of this application.
NAME/TITLE; DATE: (",v+` Off((%/,/hi1
kr PROPERTY OWNER APPLICANT .if LICENSEE /!
811149
USE THIS SPACE IF YOU NEED MORE ROOM TO DRAW A COMPLETE FLOOR PLAN
• A
•
8/1/09
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z NAME OF AFH:
SECTION 5 MUST BE COMPLETED BY THE BUILDING DEPARTMENT IN THE JURISDICTION THE HOME WILL BE LOCATED.
PLEASE CHECK ALL APPLICABLE BOXES;MATCH THE LIST BELOW TO THE APPLICANT'S FLOOR PLAN-USING THEIR
PROSPECTIVE RESIDENT BEDROOM DESIGNATIONS OFA,B,C,D,E,AND F AND CLASSIFICATION CODE:S,NSI,OR NS2
SECTION 5-BUILDING INSPECTOR'S INSPECTION CHECKLIST
R325.3 SLEEPING Room CLASSIFICATION. Each sleeping room in an adult family home shall be classified as:
Type S—where the means of egress contains stairs,elevators or platform lifts to evacuate residents to public area.
Type NSI—where 1 means of egress at grade level(has no stairs),or a ramp constructed compliant with R325.9 is provided to evacuate residents to public area.
T s e NS2—where 2 means of egress at grade level(both have no stairs),or ramps constructed compliant with R325.9 are provided to evacuate residents to public area.
SLEEPING ROOMS
Sleeping Room A 0 Type S I 0 Type NSI I 0 Type NS2 YES NO
Closet door/s are readily openable from the inside YES 0 NO 0 Smoke alarm is installed in the bedroom 0 ❑
Bedroom door is easily and quickly openable from the outside when locked 0 0
Sleeping room window has a net opening of 5.7 SF* (minimum dimensions at least 24" high; at least 20"wide) 0 0
*EXCEPT PER R310.1.1:AT-GRADE ESCAPE WINDOWS—MAY HAVE NET CLEAR OPENING 5 SF
Sleeping room window has a maximum sill height of 44"above floor,no steps under window permitted 0 0
Sleeping Room B 0 Type S 0 Type NSI 0 Type NS2 YES NO
Closet door/s are readily openable from the inside YES 0 NO 0 Smoke alarm is installed in the bedroom 0 0
Bedroom door is easily and quickly openable from the outside when locked 0 0
Sleeping room window has a net opening of 5.7 SF* (minimum dimensions at least 24" high; at least 20"wide) ❑ 0
*EXCEPT PER R310.1.1:AT-GRADE ESCAPE WINDOWS—MAY HAVE NET CLEAR OPENING 5 SF
Sleeping room window has a maximum sill height of 44"above floor,no steps under window permitted 0 0
Sleeping Room C 0 Type S I :.0 Type NSI. 0 Type NS2 YES - NO
Closet door/s arereadily openable from the inside YES,0 NO 0 Smoke alarm is installed in the bedroom ❑ 0
Bedroom door is easily and quickly openable from the outside when locked ❑. ❑
Sleeping room window has a net opening of 5.7 SF* (minimum dimensions at least 24" high; at least 20"wide) ❑i,. ❑
• *EXCEPT PER R310.1.1:AT-GRADE ESCAPE WINDOWS—MAY HAVE NET CLEAR OPENING 5 SF
Sleeping room window has a.maximum sill height of 44"above floor;,no steps under window permitted. ;_:: ❑ ❑:
Sleeping Room D 0 Type S 0 Type NSI 0 Type NS2 YES' NO
Closet door/s are readily openable from the inside YES 0 NO 0 Smoke alarm is installed in the bedroom ❑' ' ❑
Bedroom door is easily and quickly openable from the outside when locked 0 0
Sleeping room window has a net opening of 5.7 SF* (minimum dimensions at least 24" high; at least 20"wide) ❑ ❑
*EXCEPT PER R310.1.1:AT-GRADE ESCAPE WINDOWS—MAY HAVE NET CLEAR OPENING 5 SF
Sleeping room window has a maximum sill height of 44" above floor; no steps under window permitted 0 0
Sleeping Room E I 0 Type S ❑. Type NSI 0 Type NS2 YES NO
Closet door/s are readily openable from the inside YES 0 NO 0 Smoke alarm is installed in the bedroom 0 ❑
Bedroom door is easily and quickly openable from the outside when locked 0 0
Sleeping room window has a net opening of 5.7 SF* (minimum dimensions at least 24"high: at least 20"wide) ❑ ❑
*EXCEPT PER R310.1.1:AT-GRADE ESCAPE WINDOWS—MAY HAVE NET CLEAR OPENING 5 SF
Sleeping room window has a maximum sill height of 44" above floor; no steps under window permitted 0 ❑
Sleeping Room F 0 Type S 0 Type NSI ❑ Type NS2 YES NO
Closet door/s are readily openable from the inside YES ❑ NO 0 Smoke alarm is installed in the bedroom 0 ❑
Bedroom door is easily and quickly openable from the outside when locked ❑ 0
Sleeping room window has a net opening of 5.7 SF* (minimum dimensions at least 24"high; at least 20"wide) 0 ❑
*EXCEPT PER R310.1.1:AT-GRADE ESCAPE WINDOWS—MAY HAVE NET CLEAR OPENING 5 SF
Sleeping room window has a maximum sill height of 44"above floor; no steps under window permitted 0 ❑
GENERAL YES NO
Bathroom doors are easily and quickly openable from the outside when locked 0 ❑
Smoke alarms are installed on all levels of the dwelling, in each resident sleeping room, outside each separate sleeping ❑ ❑
area in the immediate vicinity of sleeping rooms(R314)
Smoke alarms are installed in such a manner so that the fire warning may be audible in all parts of the dwelling upon ❑ ❑
activation of a single device.
Access road and water supply meet local fire jurisdictional requirements 0 0
08/01/10
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R311.8 Ramps
Inside Ramp N/A YES NO
R311.8.1 Maximum Slope one unit vertical in twelve units horizontal (8.3%slope).(Exception R311.8.1 Not allowed in AFH) ❑ ❑
R311.8.2 Landing Requirements:min.3X3 foot landing at top/bottom,where doors open onto ramps,and where ramp ❑ 0
changes directions.
R325.9.1 Handrails required on both sides of ramp in accordance with R311.8.3.1 —R311.8.3.3. ❑ ❑
Outside Ramp N/A YES NO
R311.8.1 Maximum Slope one unit vertical in twelve units horizontal (8.3% slope).(Exception R311.8.1 Not allowed in AFH) 0 0
R311.8.2 Landing Requirements: min. 3X3 foot landing at top/bottom,where doors open onto ramps, and where ramp ❑ ❑
changes directions.
R325.9.1 Handrails required on both sides of ramp in accordance with R311.8.3.1 —R311.8.3.3. 0 0
*Guards below are depicted vertically as an example only. All Ramps must have Guards
Less than 4"
_ Handrail both sides
34"—38"
Guard
36"min
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ADULT FAMILY HOME RAMP
per 2009 IRC with -WA, ST AMENDMENTS
*ALL RAMPS REQUIRE A BUILDING PERMIT*
,R311.2 Means of Egress YES :NO
R31t.2 Door must be side-hinged with min.width of 32 inches between face of door and stop.Height not less than 78 inches. 0
R325.4 Operable parts of door handles,pulls,latches,locks and other devices installed in AFH shall be operable with one hand
and shall not require tight grasping,pinching or twisting of the wrist(lever-type,emergency egress hardware). The Exit doors 0 0
shall have no additional locking devices.
R311.7 Stairways I N/A YES I NO
R311.7.4.1 Riser Height: Max riser height shall be 73/4 inches (8 inches in structures built prior to July 1,2004) 0 0
R311.7.4.2 Tread Depth: Min.tread depth shall be 10 inches. (9 inches in structures built prior to July 1,2004) 0 0
R325.10.1 Handrails for Treads and Risers shall be installed on both sides of treads and risers numbering from one riser to ❑ ❑
multiple risers.Handrails shall be installed in accordance with R311.7.7.1—R311.7.7.4
R 325.8 Grab Bars in Bathrooms(May require"alternate"approval in accordance with IRC Sec.RI04.10 and.11)1 YES I NO
R325.8 Grab bars shall be installed for all water closets(toilets),bathtubs and showers.
Bathing facilities such as tubs and showers;and 0 0
On both sides of the toilet. (shall comply with ICC/ANSI A117.1 Sections 604.5,607.4&608.3) 0 0
AG103—AG 105 Swimming Pool,Spa, Hot Tub N/AI I YES NO
AG105.2 Must be surrounded by a barrier that is 48 inches high, may have doors and or gates that must have audible ❑ ❑
alarms when opened.
AG105.5 EXCEPTION:Pools,Spas or hot tubs with a safety cover which complies with ASTM F 1346 0 0
0 PASSED 0 CORRECTIONS REQUIRED 0 PERMIT REQUIRED
INSPECTOR'S SIGNATURE: DATE:
INSPECTOR'S ADDRESS: PHONE:
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.
08/01/10