2010, 05-10 AFH ChecklistG vet
cSv P040 PPLICATUON AND INSPECTION CHECKLIST - Adult Family Home
MAv \3p ; Code References: 2006 IRC Section R325 (WAC 51-51) j - l
APPLICATION NUMBER:
VIo,
�1'"SITE ADDRESS:
SECTIONS.1, 2,-3; AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED
SECTION 1 - PROPERTY INFORMATION
PROPERTY OWNER NAME:
LICENSEE NAME (IF DIFFERENT):
ASSESSOR'S TAX/PARCEL#:
SECTION 2 - APPLICANT INFORMATION
La:
DAYTIME PHONE:
DAYTIME PHONE: 5c_�?�%�C
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 BACK OF THIS PAPER IF YOU NEED MORE ROOM)
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SECTION 4 — DISCLAIMER/SIGNATURE BLOCK
I certify under penalty of pe
authorized by the owner of
have made application fo th
applicable jurisdiction for th
conducting such inspections,
which may be made by ny
the jurisdiction, inclun. its
NAME/TITLE:
❑ PROPERTY OWNER
ury tha
e above p
Department
ropri
ap
-.q
,nc!
an.
information furnished by me is true and correct to the best of my knowledge, and that I am requesting or I am
mises to request inspection for the operation of an Adult Family Home at this location. I further certify that I
Social and Health Services for an adult family home license and that I have also made application to the
ense(s) to conduct such business at this location. I further agree to hold harmless the jurisdiction
to any claim (including costs, expenses, and attorneys' fees incurred in the investigation of such claim),
the undersigned, ancMiled against the jurisdiction, but only where such claim arises out of the reliance of
ployees, upon the accuracy of the information supplied to the jurisdiction as a part of this application.
s-(!� C/d DATE: / 6
❑ APPLICANT ❑ LICENSEE
811109
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. PLEASE ALSO INDICATE ON THE FLOOR PLAN DRAWN BY APPLICANT:
WHICH BEDROOM IS #1, 2, 3, 4, 5, OR 6 AND THE CLASSIFICATION CODE: S, NS1, OR NS2 (TO MATCH THE LIST BELOW)
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 only means of egress contains stairs to evacuate.
Type NS1 — where one means of egress does not have stairs to evacuate.
Type NS2 — where two means of egress do not have stairs to evacuate.
J{.VLr i
Sleeping Room #1 ■ Type S I ■ Type NS1 ■ Type NS2
YES
NO
Closet door/s are readily openable from the inside YES ■ NO • Smoke alarm is installed in the bedroom
■
■
Bedroom door is easily and quickly openable from the outside when locked
•
■
Sleeping room window has minimum dimensions at least 24" high; at least 20" wide —(NET OPEN -ABLE AREA OF 5.7 SF*")
■
■
""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 #2 ■ Type S ■ Type NS1 ■ Type NS2
YES
NO
Closet door/s are readily openable from the inside YES ■ 1 NO ■ I Smoke alarm is installed in the bedroom
■
■
Bedroom door is easily and quickly openable from the outside when locked
■
■
Sleeping room window has minimum dimensions at least 24" high; at least 20" wide —(NET OPEN ABLE AREA OF 5.7 SF **)
■
■
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 #3 • Type S I • Type NS1 ■ Type NS2
YES
NO
Closet door/s are readily openable from the inside YES • NO • Smoke alarm is installed in the bedroom
■
■
Bedroom door is easily and quickly openable from the outside when locked
•
■
Sleeping room window has minimum dimensions at least 24" high; at least 20" wide —(NET OPENABLEAREA OF5.7SF*'`)
■
■
**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 #4 ■ Type S ■ Type NS1 ■ Type NS2
YES
NO
■
•
Closet door/s are readily openable from the inside YES • NO ■ Smoke alarm is installed in the bedroom
Bedroom door is easily and quickly openable from the outside when locked
■
■
Sleeping room window has minimum dimensions at least 24" high; at Ieast 20" wide —(NET OPEN ABLE AREA OF 57 SF**)
■
■
*"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 #5 ■ Type S ■ Type NS1 ■ Type NS2
YES
NO
Closet doorls are readily openable from the inside YES ■ NO • Smoke alarm is installed in the bedroom
■
■
Bedroom door is easily and quickly openable from the outside when locked
■
■
Sleeping room window has minimum dimensions at least 24" high; at least 20" wide —(NET OPENABLEAREA OF 5.7SF"*)
■
■
■
'`*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 #6 ■ Type S I ■ Type NS1 ■ Type NS2
YES
NO
Closet door/s are readily openable from the inside YES • NO • Smoke alarm is installed in the bedroom
■
■
Bedroom door is easily and quickly openable from the outside when locked
■
■
Sleeping room window has minimum dimensions at least 24" high; at least 20" wide —(NET OPEN -ABLE AREA OF5.7SF**)
■
■
**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
•
■
GENERAL
Bathroom doors are easily and quickly openable from the outside when locked
YES NO
Smoke alarms are installed on all levels of the dwelling, in each bedroom and common areas ❑
Any smoke alarm must be audible throughout the home when activated. 0
Access road and water supply meet local fire jurisdictional requirements ❑
811109
R311.6 Ramps
Inside Ramp If NIA r here
YES
NO
R311.6.1 Maximum Slope one unit vertical in twelve units horizontal (8.3% slope).
•
•
R311.6.2 Landing Requirements: min. 3X3 foot landing at top/bottom, where doors open onto
ramps, and where ramp changes directions.
II
•
R311.6.3 Handrails required (on both sides of ramp: per state licensing requirement WAC 388-76-10730).
II
IN
Outside Ramp If N/A 0 here
YES
NO
R311.6.1 Maximum Slope one unit vertical in twelve units horizontal (8.3% slope).
•
•
R311.6.2 Landing Requirements: min. 3X3 foot landing at top/bottom, where doors open onto
ramps, and where ramp changes directions.
•
•
R311.6.3 Handrails required (on both sides of ramp: per state licensing requirement WAC 388-76-10730)
II
•
**Guards below are depicted vertically as an example only.
Less than 4"
Guard
36" min
3'x3'min
landing
min
1:12 max slope
8.3%
Handrail both sides
34" —36"
3'x3'min
landing
ADULT FAMLY HOME RAMP
per 2006 IRC with WA. ST. AMENDMENTS
*ALL RAMPS REQUIRE A BUILDING PERMIT*
3'
min
R311 Means of Egress
YES
NO
R311.4.2 Door Type and Size: Side -hinged not less than 3 feet in width and 6 feet 8 inches in height.
■
■
R311.4.4 Type of lock or latch: readily openable from the side from which egress is to be made without
the use of a key or special knowledge or effort.
R311.5 Stairways If N/A B here',
YES
NO
R311.5.3.1 Riser Height: Max riser height shall be 73/4 inches (8 inches in structures built prior to July 1, 2004)
•
■
R311.5.3.2 Tread Depth: Min. tread depth shall be 10 inches. (9 inches in structures built prior to July 1, 2004)
IN
•
R311.5.6 Handrails required on both sides of one riser or more (per state licensing requirement WAC 388-76-10730)
•
■
Grab Bars in Bathrooms
YES
NO
WAC 388-76-10730 The AFH must install and securely fasten grab bars (not suction cup style) to meet the
needs of residents in:
■
■
Bathing facilities such as tubs and showers; and
■
■
On both sides of the toilet fif structurally not feasible use type that affix to toilet seat)
■
■
AG101 Swimming Pool, Spa. Hot Tub 1 If N/A 0 her
YES
NO
AG105 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: Spas or hot tubs with a safety cover which complies with ASTM F 1346
•
■
❑ PASSED
❑ CORRECTIONS REQUIRED
INSPECTOR'S SIGNATURE:
❑ PERMIT REQUIRED
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.
811109
USE THIS SPACE IF YOU NEED MORE ROOM TO DRAW A COMPLETE FLOOR PLAN
8/1/09