2007, 01-17 Permit App: 07000142 Safety Inspect Permit Center
S io` kane PERMIT NUMBER:7�
11707 E Sprague Ave, Suite 106 ���
ValleSpokane Valley,WA 99206 PERMIT FEE: ��
.7 (509)688-0036 FAX: (509)688-0037
Community Development www.spokanevalley.org
Safety Inspection F .Adult Family Home-WABO
Permit Application Fire/Water/Vehicle Damage
Other:
SITE ADDRESS %013/9 l f ,,e
wk.re-st Pr /674-A401)
ASSESSORS PARCEL NO: ysa 702 ,(9/y„2 LEGAL DESCRIPTION:2..Q_ SCC WA-ft Ir-•W 3d Pte 1--
4 Z AL*,
Building Owner: Contractor:
Name: Xs d he,1 t off,4v, Name:
Address: Q//h L. - MO l/ /4Ve- */573 Address:
City:4PACti n lig 1,Y State: ,j/A_ 0706 City: State: Zip:
Phone:9/7--;VR^ . Fax: F�'9v/1/3 77 Phone: Fax:
r- Contractor Lic No: Exp Date:
JJr1,
Contact Perso 7311,
rOf y City Business Lic.No:
Name: 7
Phone: ,2/,— gIS
Describe the scope of work in detail: Cost of Project: $
**************The following MUST be comTete: (write N/A if not applicable)**********************
HEIGHT TO PEAK: y, 4. DIMENSIONS: a / /4_ #OF STORIES: TOTAL HABITABLE SPACE:
MAIN FLOOR TO SQ. 2Nu 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 Date
Method of Payment:
❑ CashCheck ❑ Mastercard ❑ VISA
Bankcard#: Expires: VIN#:
Authorized Signatu -:
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 Nw4;ER:
Applicant must complete sections 1, 2, 3, and 4. Application must be complete to be processed.
SECTION 1- PROPERTY INFORMATION
SITE ADDRESS: �a 3/y E/9 ASSESSOR'S TAX/PARCEL#:�� 1
SECTION 2-APPLICANT INFORMATION
PROPERTY OWNER NAME: S d p G1 r 0p �7(-; / p DAYTIME PHONE: 36 0[ -/07/3 C�
LICENSEE NAME(IF DIFFERENT): St/h g/thh19J1 Q 6 T jy1 Vcf L I (� DAYTIME PHONE: /7"' /ce l
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)
Lvjz.ntAIL-ct- `CO Y
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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(induding costs,expenses,and attorneys'fees incurred in
the investigation of such daim),which may be made by any person,including 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 appli tion.
NAME/TITLE: i DATE: /
PROPERTY OWNER 0 APPLICANT 0 LICENS E
i Pk
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 0
Sleeping Room #1 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 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 ❑
Sleeping Room #2 0 S ❑ NSI 0 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 El ❑
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 #3 0 S 0 NS 1 ❑ 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 0 El
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions-24"high;20"wide) 0 El
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 ❑
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 0
Sleeping Room #5 ❑ S 0 NS1 0 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 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 ❑ S El NS1 ❑ NS2
Bedroom door is openable from the outside when locked El 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" ❑ ❑
GENERAL
Bathroom doors are openable from the outside when locked ❑ ❑
Smoke alarms are installed on all levels of the dwelling ❑ El
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 El ❑
❑ 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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Statement of Deficiencies .. _._ License r:481404 Completion
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Page 4 of 4
dwelling. Findings include:
Based��'' on observation= during the 12/19/06 licensing inspection, the window in Resident#4's
bedroom measured 48 inches fromthe rondo \ :)ill to the floor. A .wood step was located inukr
the bedroom window. The step measured 4 1/4 inches high, 11 1/4 inches wide and 22 3/4
inches long, The w Sidiiin Resident
Gszdtit --'a bedroom
eurtimuxccedLd current building
i[t 11g code
requirements for sill-to-floor height of 44 inches.
According to the provider, the resident was "shaky” when she walked and used a front-wheeled
walker for routine ambulation. In the event of an emergency evacuation, the provider said she
would use a wheelchair to transport the resident to safety. During an interview on 12/19/06, the
provider said she was not sure if the home met current state and local building codes.
POC Date:
POC: _ ��