1998, 07-27 Req for InspectionSSHS 21-38A
SEE INSTRUCTIONS ON REVERSE SIDE
a
RECEIVED - WSp/Fpg
DEPARTMENT OF COMMUNITY DEVELOPMENT — FIRE PROTECTION SERVICES DIVISION
REQUEST FOR INSPECTION
y -
I.D. NO.>;0'1 '" JUL 2 7 1998
! PROPERTY TO BE INSPECTED I COUNTY: SPOKANE
2. I INSPECTION REQUESTED BY
TAME: KID CITY PRESCHOOL & DAYCARE CENTER
REOUESTOR
NAME: Linda S. Ernst
AGENCY: OCCP Region 1
.DDRESS:
5920 East 9th Ave
ADDRESS: PC Rox 253R
:ITY:
Spokane c'o0E: 99212
ZIP
CITY: Spokane co0E: 99220
'EPSON TO
;ONTACT: LUCenette Hicks pHO4509)535-7817
pHcN44509)a56-4017 DATE: 5/22/98
TYPE INSPECTION REQUESTED
NEW LICENSEREINSPECTION
XXX
LICENSING INSPECTION
I LICENSE RENEWAL I SPECIAL INSPECTION
REQUESTED OR LICENSED OCCUPANT CAPACITY
AGE
INSPECTION, OTHER: No.: 42 GROUP:1 mon TO 12 YEARS
CURRENT LICENSE
EXPIRES ON: I OTHER:
. I FACILITY TO BE LICENSED AS
MINI DAY CARE CENTER (in residence) GROUP CARE FACILITY GROUP CARE FACILITY FOR SEVERELY
_ ANDMULTIPLE HANDICAPPED
MINI DAY CARE CENTER (nonresidence) MATERNITY SERVICE
._ ,_ _,.
DAY CARE CENTER (in residence) DAY TREATMENT FACILITY JUVENILE DETENTION FACILITY
XXXX DAY CARE CENTER (non-reaidence) TRANSIENT ACCOMMODATION OTHER'
NFORMATION — """
REQUESTED:
{.I TOFORWARDED ' /-� `� '7 DATE: v/a J l"l ii EPL BY: PHOTO REO. ll YES ❑ NO
( L/ /
FACILITY INSPECTION
INSPECTOR INSPECTION -' �
NAME: "vt A /i DATE:`�,J 126 V t U
3EINSPECTION REQUIRED? LJ YES ❑ NO DATE NEXT INSPECTION/REINSPECTION SCHEDULED:
OCCUPANCY
1 YES
1 MANUAL F RE
NO I AUTOMATIC i VES I NO
DETECTION AUTOMATIC
YES
NO PARTIALS SINGLE STATION
IYES
NO
COMMERCIAL
RANGE HOOD
yE S NO
TYPE
I ALARM SYSTEM I
I SYSTEM I I I SPRINKLERS:
I II SMOKE DETECTORS
SYSTEM:
I
CONSTRUCTION
BASEMENT OR
VEST NO
SYSTEM CONFIGURATION: APPROVED FIRE ESCAPE(S)
NUMBER
STORIES' CELLAR?
,EXIT _
I I
COMMON INTERIOR CORRIDORS WITH COMMON INTERIOR CORRIDORS WITH APPROVED OUTSIDE STAIRWAYS TO
_
ENCLOSED INTERIOR STAIRWAYS UNENCLOSED INTERIOR STAIRWAYS GROUND LEVEL
COMMON INTERIOR CORRIDORS OPENING EXTERIOR EXIT BALCONY WITH TWO
—
ONTO APPROVED OUTSIDE STAIRWAYS STAIRWAYS TO GROUND LEVEL
DIRECT EXITIN TO ADJACENT GRADE
_
ATTACHMENTS: LJ FPS 221 / 222 LETTER L i PHOT APHIS) INSPECTION REPORT LJ FPS 223/226 I OGG PANCY PERMIT Li STATUS REPORT
DETAILS OR RESTRICTIONS F /-
I ti
G%,1}' '\�-+D "p"' k �2
J APPROVED FOR LICENSING
.
I FIRE PROTECTION SERVICES DIVISION
DISAPPROVED: DEFICIENCIES ON ATTACHED REPORT MUST BE CORRECTED BEFORE APPROVAL IS GRANTED
FACILITY INSPECTED FOR COMPLIANCE WITH WAC
212
J OT APPLICABLE: SEE ASO MEN S OR ATTACHED REPORT
MILESDRIVEN FROM LAST INSP
MRS REQUIRED FOR INSP
/
NO. DEFICIENCIES IDENTIFIED
NO. DEFICIENCIES CORRECTED
3Y:\kJ DATE
SPACE ALLOCATION
3.1 ACTION BY FIRE PROTECTION SERVICES DIVISION
A-3 SF R-1 SF
8-2 SF R-3 SF
REVIEWED
3Y: DATE:
E-3 SF SF
APPROVE g3 i1 d Hs
BY: DATE' (J
��
SF SF
FORW'AROED
REOUESTOR BY: DATE:
TOTAL SF'
S FORM224 NOVEMSER t 978 a355-
Write Copy —Fire Protection Services Division
Canary Copy —Impactor Copy Pink Copy-05HS Copy Goldenrod Copy —General Use
Division of Child and Family Services
AF .CATION FOR CHILD DAY CARE CE..(ER
LICENSE OR CERTIFICATION
. NAME OF �F3ACLIT.7AGEEN Or parent 0 anrzation, if an
:. ADDRESS OF FACUTY/AGENC. (or parent organization, if any): ^ CTY
/
(<ivte
3. NAME OF FACLIY/AGENCY BRANCH OR SUBDIVISION OF AGENCY, OR NAME 9Y WHICH AGENCY DOES BUSINESS (d/b/a):
t. ADDRESS OF FACILITY TO BE UCNSEED IF DIFFERENT THAN IN NUMBER 2 ABOVE: STREET
i. MAILING ADDRESS IF DIFFERENT THAN ABOVE: STREET
COUNTY
ZIP CODE
TELEPHONE:
557fi7
CITY
LINTY
ZIP CODE
QTY
COUNTY
2IP CODE
B. DIRECTIONS FOR REACHING'FACUTY TOBEUCNSED:
/0V-0-691 , •\ La irlHl �+%C.. /0(2, ✓� V / ` /�llAi A !� ' Strom '
S$ $freer`
C:7'ti/// r� %eel i y 7 r,u
7 �f•
f Gr �1C Trevim% P...S 14 1 L/ Mild
. TELEPHONE NUMBER OF APPUCANT (if new application):
& LX:ZZNSING RECORD:
. ❑ First Renewal 0 Certification • Other (specify)
). CLIENTELE PREFERRED: 1 I NUMBE$�
0 Male 0 Female It Either Sex 0 Expectant Mothers ``//))'"//
RANGE OF AGES PREFERRED:
"MC / 0
1a HAVE YOU REVIOUSLY BEEN UCNSZD OR CERI1FIED?
YES ❑ NO
IF YES. INDICATE BY WHAT NAM LA DWHERE
S --t,/ 574*
FROM: To: OR: No Age Preference
la. THE FACT WILL BE LOCATED IN (dwet one):
❑ Incorporated City
Unincorporated County
110. IF YOU ARE AWARE OF WHICH LOGLZONING,PLANNING. OR BUILDING CODEAGENCYOES)LS RESPONSIB LE FOR THE LOCALITY IN WHICH THE
FACL I Y W ILL 3E LOCATED. PLEASE SPECIFY:
.
2. TY E Of ORGANIZATION (Check appropnate hazel):
Individual 0 Non -Profit Corporation 0 Governmental Agency
Partnership or Non -incorporated Association 0 Proprietary Corporation ■ Indian Tribe
3.
B SFDAPER
*sJc MA& iron HJLCt vgA6E1iaiSitkiataattail'£For7�N
rAME OF PERSON FORWH
HOM REFERENC__E//S//AAAE GNEN (Resume of person for whom °Blow references are given should be attacned):
OM AA
Atee ene
NAME OF RENC
ADDRESS
TELEPHONE
�`�/ Ilnn I^
,c111 L 1tM
�^
/
3 n ,J/ c Vi - 7 +—t(-3,c )' =
ctt.1 ).2":. _',
lb,' �C�cxi�
/ �G E 3s =
c59)335--3.72
l,
kitittii atet29>Z64.056.
14. Has applicant or any other staff member (atnchastatement ofexplanation for any 'Yes"answer): Yes No
a. Been convicted of any crime? 0 S
b. Had a serious injury, illness been hospitalized during the past year, or is currently under medication,
or has a history of mental or physical limitations? O ❑
c Been found to be a perpetrator of substantiated child abuse? -. , . 0
I 5. Has applicant or chief executive officer (arrant a statement ofexp/anation for any 'Yes' answer):
Yes N
a. Engaged in the illegal use of drugs ? .. ❑
b. Excessive use of alcohol? ❑
c Been convicted of a felony? ❑
Yes
d. Been released from prison in the past seven years ? ... ❑ �i,
e. Been denied a license to care for children or adults ? .. ❑ IL,s
f. Had a license to care for children or adults suspended
or revoked ? ❑
)SHS 10-008A( X) PAGE 3(3131) •e0