2007, 01-24 Permit App: 07000220 Safety Inspect - _
caT��r � • � Permit Ce t `, \ } PERMIT NUMBER: L AZ2
+akane 11707 E S � 4e Ave, Suite 106
Spokane V e AWA ' 1 ,ff^�
���� (509)688-0 6_FAX: �0) 8-0037 ( , PERMIT FEE:
Community Development www.spoka vahtev.org \\ ,`-�+�;
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Safety Inspection \Adult Family Home
Permit Application Fire/Water/Vehicle Damage
Other:
SITE ADDRESS fr ' / 5 .6 ./V /n.)to N v
ASSESSORS PARCEL NO: LEGAL DESCRIPTION:
Building Owner: Contractor:
Name: mil 4- lJ r `1 o A R n s b e S Name:
Address: i o�') I �- C �,' 1, /1-0-e-
City:
City: C„v } f 1- I'-,/State:w� Zip:7 j.4� Ci40 ty: State: Zip:
Phone:' V Fax: Phone: Fax:
y.)-7 —�.7 /a
Contractor Lic No: Exp Date:
Contact Person ��}} City Business Lic.No:
Name: 'Eren.)D A- K2iND-eCs
Phone: 97--,17/ D
Describe the scope of work in detail: Cost of Project: $
�Z,r se c,c s t L, n et f
**************The following MUST beComplete: (write N/A if not applicable)**********************
HEIGHT TO PEAK: DIMENSIONS: #OF STORIES: TOTAL HABITABLE SPA j
,9-?o O S'`- `jj VII f'
MAIN FLOOR TO SQ. 2"" FLOOR SQ. FTG: UNFIN BASEMENT SQ. FTG: IMPERVIOUS SURFAC
FTG: A/�- AREA:
FINISHED BASEMENT GARAGE SQ. FTG: DECK/COV. PATIO SQ. FTG: 30% SLOPES ON
SQ. FTG: / 00 /,)--0 fr '-1 0 PROPERTY: A) Pt-
#OF BEDROO S: CO .STRUCTION TYPE: HEAT SOURCE: rorc -D f r;SEWER OR SEPTIC?
.3 m A..N . (a D v" LJ J r A vv e_ .1 CS a s ) I •(e,e fry C, -e-� C.r
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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.
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Signature Date //,2_
/
Method of Payment:
❑ Cash ❑ Check ❑ Mastercard ❑ VISA
Bankcard#: Expires: VIN#:
Authorized Signature:
REVISED 8/25/2005
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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: /.?-• / 5� L V/A t X /1/)(- ASSESSOR'S TAX/PARCEL#: -
SECTION 2-APPLICANT INFORMATION /
PROPERTY OWNER NAME: 4._ R(/P)4;DA- R
Th
,( e;,)i •i' Cr,CS DAYTIME PHONE: - —�
? -7/0
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LICENSEE NAME(IF DIFFERENT): ) rJ D A- Qac.A3 b -Y'S DAYTIME PHONE: 117.--7- 3 7 , (,,
SECTION 3—FLOOR PLAN
A complete floor plan must indude 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)
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SECTION 4—DISCLAIMER/SIGNATURE BLOCK
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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 Soda!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 daim(induding 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 the accuracy of the information supplied to the
jurisdiction as a part of application.
NAME/TITLE: i Z�1/�Zr-C�/ DATE: // 2 q/0-2
x'
PROPERTY OWNER X APPLICANT )Z�J 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 ❑ ❑
SLEEPING ROOMS 0 0
Sleeping Room #1 0 S 0 NS1 0 NS2
Bedroom door is openable from the outside when locked ❑ ❑
Closet doors are readily openable from the inside 0 0
Smoke alarm is installed in the bedroom 0 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 0
Sleeping Room #2 0 S 0 NS1 0 NS2
Bedroom door is openable from the outside when locked 0 0
Closet doors are readily openable from the inside 0 0
Smoke alarm is installed in the bedroom 0 0
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" 0 0
Sleeping Room #3 0 S 0 NS1 0 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 0
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" 0 0
Sleeping Room #4 0 S 0 NS1 0 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 0 0
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" 0 0
Sleeping Room #5 0 S 0 NS 1 0 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 0
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" 0 0
Sleeping Room #6 0 S ❑ NS1 0 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 ❑ ❑
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" 0 0
GENERAL
Bathroom doors are openable from the outside when locked 0 ❑
Smoke alarms are installed on all levels of the dwelling 0 0
All smoke alarms are audible in all parts of the dwelling upon activation of a single device ❑ 0
Access road and water supply approved by Fire Department 0 0
0 PASSED 0 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.