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2007, 03-07 Permit App 07000714 AFH Safety InspectionPermit Center S( iT 1' tY pokane 11707 E Sprague Ave, Suite 106 Valley Spokane Valley, WA 99206 V(5 9)688-0036 FAX: (509)688-0037 Community Development w <s okanevalley.21g\V/ I:c Safety Inspection Permit Application MAR 0,? 2007 (1AIl[ f l ,nil PERMIT NUMBER: 6 7'C 7!Lf PERMIT FEE: Adult Family Home Fire/Water/Vehicle Damage Other: 1' SITE ADDRESS vL re E - l� ASSESSORS PARCEL NO: ilQ3 , I51 VOL thAl v J 4)00 LEGAL DESCRIPTIO' . Building Owner: Name,,—,, KE eiti ,'' Address: 4, d) City: i \ State: Zip:C f j) t%, Phone: `1 Fax: Contact Person Name: I l ll>u rj ly �lA cll"� i Phone: Describe the scope of work in detail: **************The following MUS Contractor: Name: Address: City: State: Zip: Phone: Fax: Contractor Lic No: Exp Date: City Business Lic. No: Cost of Project: $ T be complete: (write N/A if no applicablel********************** HEIGHT TOt\iPEA�K: DIMENSIONS: # OF STORIES: TOTAL HABITABLE SPACE: MAIN FLOOR FTG: 1 Iv TO SQ. 2Nu FLOOR SQ. FTG: UNFIN BASEMENT Q. FTG: Pt IMPERVIOUS SURFACE AREA: FINISHED BASEMENT SQ. FTG: Jai i t GARAGE SQ. FTG: � A- DECK/C V. PATI� SQ. FTG: �j 30% SLOPES ON PROPERTY: N , # OF BEDROO S: *,Vci0irNda rCTION TYPE: }dATSyeREn-C k SEWER�RkPTIC? 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 Valle Permit Center. 5) This City of Spokane Valley Permit is not a permit or approval for any violation of federal, state or local laws, cogs pr ordinances. 6) Plans or additional information may be required to be submitted, and subsequently approved before this applicatin be process d. Signatu Method of Payment: ❑ Cash Bankcard #: Authorized Signature: REVISED 8/25/2005 ❑ Check ❑ Mastercard Expires: Date ❑ VISA VIN#: APPLICATION AND INSPECTION CHECKLIST - Adult Family Home Code References: 2003 IBC 310 (WAC 51-50) and 2003 IRC 110 (WAC 51-51) APPLICATION uWIBEEC: Applicant must complete sections 1, 2, 3, and 4. Application must be complete to be processed. SECTION 1- PROPERTY INFORMATION SITE ADDRESS: Tj 6 E PROPERTY OWNER NAME: LICENSEE NAME (IF DIFFERENT): ii to i t ti 6v; ES OR'S TAX/PARCEL #: SECTION 2 - APPLICANT INFORMATION DAYTIME PHONE: 0 47 L "��i e" L(- DAYTIME PHONE: 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) SECTION 4— DISCLAIMER/SIGNATURE BLOCK I certify under penalty of perjury that the information fumished 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 attomeys' fees incurred in the investigation o `ems idi claim), which may be made by any person, including the undersigned, and filed against the jurisdiction, but only where such claim arises Fut.f the reliance oft a jurisdiction, in d'ng its officers and-mployees, upon the accura9' of the information supplied to the jurisdiction as e NAME/TITLE: PROPERTY OWNER T APPLICANT ❑ LICENSEE DATE: � lei SECTION 5 - INSPECTION CHECKLIST Note: Checklist to be completed by building department in the jurisdiction home will be located. Home licensed (or applying for license) on or after July 1, 2001 SLEEPING ROOMS Sleeping Room #1 ❑ S ❑ NS1 ❑ NS2 Bedroom door is openabte 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 #2 ❑ S 0 NS1 0 NS2 Bedroom door is openabte 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 #3 ❑ S 0 NS 1 ❑ NS2 Bedroom door is openabte 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 #4 0 S 0 NS 1 ❑ 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 0 NS 1 0 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 #6 ❑ 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" GENERAL Bathroom doors are openabte 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 YES NO ❑ ❑ O ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ O 0 O 0 O 0 ❑ ❑ O 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ O 0 ❑ ❑ O 0 ❑ ❑ O 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 0 O 0 O 0 O 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 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.