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
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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.