2006, 03-24 Permit App: 08000334 Adult Family Home c.
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.
n SECTION 1 - PROPERTY INFORMATION
SITE ADDRESS: cowl I L • I I tk Pt U£ ASSESSOR'S T• CID•: 3 5 a LI 3- D d oct
SECTION 2-APPLICANT INFORMATION•
7ROPERTY OWNER NAME: C.,CAA t /-14 S U. C r DAYTIME PHONE: .7 33 c 7Clel
LICENSEE NAME(IF DIFFERENT): Li l G 4c.. d c.r 2.11; DAYTIME PHONE: )3 1 ` 3 7 7 8
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)
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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 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 daim(including costs,expenses,and attorneys'fees incurred in
the investigation of such claim),which may be made by any person,induding the undersigned,and filed against the jurisdiction,but only where
such daim arises out of the reliance of the jurisdiction,induding its officers and employees,upon the accuracy of the information supplied to the
jurisdiction as a part of this application. PQM(
NAME/TITLE: L O O L 11 m t l s G roLto 1-lortga
0 PROPERTY OWNERAPPLICANT 16 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 ❑ ❑
Sleeping Room #1 ❑ S ❑ 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 ❑ ❑
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions-W high;20"wide) ❑ 0
Sleeping room window has a maximum sill height of 44" 0 0
Sleeping Room #2 ❑ 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
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 #3 0 S ❑ NS 1 ❑i NS2
Bedroom door is openable from the outside when locked ❑ ❑
Closet doors are readily openable from the inside U ❑
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
Sleeping room window has a maximum sill height of 44" ❑ ❑
Sleeping Room #4 0 S 0 NS 1 ❑ 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 ❑ ❑
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 0 NS1 0 NS2
Bedroom door is openable from the outside when locked 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) ❑ ❑
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 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) ❑ ❑
Sleeping room window has a maximum sill height of 44" 0 0
GENERAL
Bathroom doors are openable from the outside when locked ❑ ❑
Smoke alarms are installed on all levels of the dwelling ❑ ❑
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 0 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.
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