2006, 09-06 Permit App: 06003546 Safety Inspect 09/05/2006 17: 16 5099273340 HENDERSON HOMES PAGE 01/01
Permit Center �'
LA
o ]1e 11707 E Sprague Ave,Suite 106 PERMITNL>TSER: 3C{
Spokane Valley,WA 99206
Valley (509)688-0036 FAX: (509)688-0037 PERMIT FEE: y 7
Community Development Ivww.sool.-anevall o ,co
Multi-Family
Construction o New Construction o Addition/Reinodei
Permit A _plication ❑ Other:
E A/'j 1/lC
SITE ADDRESS / :'27/Or) C) 19 r
ASSESSORS PARCEL NO:4 .:X'a. l L?3 LEGAL DESCRIPTION:
Bulletin: owner A MILV.L ! I Conta.ctYIr - �.
-
Name: Name:
.Maria:Cr/Contact Person %
�..� !!._ �: ��r 4 Address:
Address: ' ' - 1.,.)....4-44%.,
+.�—. " ....• l=ily: State: Zip:
Phone: Fax:
Phone: Fax: Lic No: Exp.Date:
Contact Person PersonillAMITraill78 � � `�� City Business Lie No:
Name: `IliJ'Cl1ltQFk,�gDtir.°+;�:•i ' .arra*,,....�., R. .,..,,;,.r:.�rt r
;iw � W,''1+1Mri".•1p•t___ ,•ref'.^.
Phone: .- • -- 1 s� r�':_
1p► -- 3 q Company Name:
Architect Name:
Cost of Project: Address:
City: State: Zip:
Describe the scope of work'i oictail: , Phone: Fax:
+ L
A -
Type of Construction Occupancy Total Building Sq Ft
No. of Stories No. of Units Deck Carport/Garage
Beat Source Fire Sprinklers
DISCLAIMER
The permitoe 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 applicat n bo processed.
Signet e / ./i_.i _ _ /�A /i....I� w Date_, / Wi C:,
Method of Payment (Faxed permit applications will only be accepted with majorbankcard)
0 Cash 0 Check 0 Mastercard 0 VISA 0 Other
Bankcard#: Expires: VlN#:
Authorized Signature:
REVISED 825.2006
craoo'D777A fit PQf;P 21
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.
JJ SECTION 1 - PROPERTY INFORMATION
SITE ADDRESS: I /,Oa (O I/9 ,' V e. ASSESSOR'S TAX/PARCEL#: -
SECTION 2- APPLICANT INFORMATION
PROPERTY OWNER NAME: CO Cly,t1 (1 p' $•, �y U I a( 1� DAYTIME PHONE: O 93'973 2'
LICENSEE NAME SIF DIFFERENT): C` V}L 42 V\ Q l'A pinl``P.I V-0 DAYTIME PHONE: q a' --2„1.-/3
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 necessary)
r
: r1t
7
.CL
,,f'\-- A
1 /
t I
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 claim(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 asap f this appli • n. 10
NAME/TITLE: �. Q40 DATE: 4 i -143 ) c9.4&_X-,
/
0 PROPERTY OWNER 0 APPLICANT 7a 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 ❑ ❑
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) 0 ❑
Sleeping room window has a maximum sill height of 44" ❑ ❑
Sleeping Room #2 ❑ 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
Sleeping room window has a maximum sill height of 44" ❑ ❑
Sleeping Room #3 ❑ S ❑NS1 ❑ 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 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
Sleeping Room #4 ❑ 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) ❑ ❑
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 ❑ ❑
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" El ❑
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 ❑ ❑
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 ❑ ❑
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.