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20120822124559809.pdfREcEIVE D r FEB 0 2 200E PERMIT COUNTER REQUEST FOR INSPECTION- Adult Family Home % APPLICATION NUMBER.. ` 60(o Applicant must complete sections 1, 2, 3, and 4. Application must be complete to be processed. SITE ADDRESS: `-h J !may' ASSESSORS TAX/PARCEL #: - -s�� ----------- PROPERTY OWNER NAME: &10d'6)u I1 P / 4a DAYTIME PHONE: Z0 ?' S LICENSEE NAME (IF DIFFERENT): DAYTIME PHONE: A complete floor plan must include all sleeping rooms, identified by number (#l, #2, #3 etc.) and all components for exiting, i.e. stairs, ramps, platform lifts and elevators. (Attach additional sheets if necessary) 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 authorized by the owner of the above premises to request inspection for and operate an Adult Family Home at this location. I further certify that I have made application to the Department of Social and Health Services and the 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 (including 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 as a part of this application. NAME/TITLE: 14 dou ISP ! / DATE: VPROPERTY OWNER NKAPPLICANT d�1 LICENSEE 'zs1If lyi PASSED CORRECTIONS REQUIRED J PERMIT REQUIRED DATE: TZ.,'07 YES NO Home licensed (or applying for license) on or after July 1, 2001 7 SLEEPING ROOMS (� Sleeping Room #1 -1 S -_ NS1 X i NS2 Bedroom door is openable from the outside when locked ,; l Closet doors are readily openable from the inside J Smoke alarm is installed in the bedroom j Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide) elf J Sleeping room window has a maximum sill height of 44" J Sleeping Room #2 S - NSI % 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 J Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide) i 1 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 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 A 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 I S NSI NS2 Bedroom door is openable from the outside when locked Closet doors are readily openable from the inside Smoke alarm is installed in the bedroomh Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide) J Sleeping room window has a maximum sill height of 44" Sleeping Room #6 -1 S NSI NS2 Bedroom door is openable from the outside when locked F- -1 Closet doors are readily openable from the inside 1`' ! Smoke alarm is installed in the bedroom p Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide) i _ _I Sleeping room window has a maximum sill height of 44" L _J 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 4` PASSED CORRECTIONS REQUIRED J PERMIT REQUIRED DATE: TZ.,'07