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20120822130240051.pdfAPPLICATION AND INSPECTION CHECKLIST - Adult Family Home Code References: 2006 IRC Section R325 (WAC 51-51) APPLICATION NUMBER: SECTIONS 1, 2, 3, AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED SITE ADDRESS: L 3 3 2 6 ✓ 1 TH PL w t Ute) UNoS . ?O? © ASSESSOR'S TAX/PARCEL#: 00'4 ( OQ 000 10C' 111111111111111MMIMM!• • PROPERTY OWNER NAME: c G U G fN //q M 1 C1,,fA ,YTIME PHONE: 206 2 -To / y g// LICENSEE NAME (IF DIFFERENT): DAYTIME PHONE: • ••• -3 Will 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 Fal ELEVATORS. (USE BACK OF THIS PAPER IF YOU NEED MORE ROOM) RECEIVED 1 8 2010 t TTY ` EVELOPM9ENT SERVICES GTR, CITY OF EDMROND S DN 4'- DISCLAIMER/SIGNATURE BLC I certify under penalty of perjury that the information furnished 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 have made 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 cl im (including costs, expenses, and attorneys' fees incurred in the investigation of such claim), which may be made by any person, including the under igned, and fit d against the jurisdiction, but only where such claim arises out of the reliance of the jurisdiction, including s officers and employees, u the and y of the information supplied to the jurisdiction as apart of this application. NAME/TITLE: \ DATE: 06 6 / 2 010 Q PROPERTY 8/1109 'S °6P s�zz� 'NAME OF 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 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 NSi -where one means of egress does not have stairs to evacuate. Tvve NS2 -where two means of eqress do not have stairs to evacuate. SLEEPING ROOMS Sleeping Room #1 ❑ Type S Type NS1 ❑ Type NS2 YES NO Closet doorls are readily openable from the inside YES ❑ 1 NO ❑ Smoke alarm is installed in the bedroom. ❑ 0 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-(NETOPENABLEAREA 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 NSl. ❑ Type' NS2 YES NO Closet door/s are readilyopenable 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-(NETOPEN-ABLE AREA OF 5.7 SF *') "EXCEPT PER R310.1.1: AT -GRADE ESCAPE WINDOWS -(MAY HAVE NET CLEAR OPENING 5 SF ) ❑ El Sleeping room window has a maximum sill height of 44" above floor; no steps under window permitted ❑ ❑ Sleeping Room #3 ❑ Type S Type NSi ❑ 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 operable from the outside when TckeT ❑ ❑ Sleeping room window has minimum dimensions at least 24" high; at least 20" wide -(NET OPEN -ABLE AREA OF 5.7 SF*') *kEXCEPT 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 NSi El Type NS2 YES NO Closet doorls are readily openable fromthe inside IYES ❑ NO 1:11 Smoke alarm is installed in the bedroom ❑ ❑ Bedroom door is easily and quickly openable from the outside when rocked ❑ El Sleeping room window has minimum dimensions at least 24' high; at least 20" wide-(NETOPEN-ABLEAREA 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 #5 ❑ Type S Type NSI ❑ 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.atleast 24" high; at least 20" wide-(NETOPENABLEAREA 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 #6 Type S ` Type NSi Type NS2:: YES NO,. Closet door/s are readily openable from the inside yes°❑ NO ❑ Smo e alarm is installed in the bedroom ❑ ❑ Bedroom door is easily and quickly op.en.ablefrom the outside when locked 0 ' ❑ Sleeping room window has ninimum.dimensions at.least 24" high; at least20" wide-(NETOPEN-ABLE AREA OF5.7 SF'*) x*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 ❑El GENERAL YES NO Bathroom doors are easily and quickly openable from the outside when locked ❑ ❑ 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. ❑ ❑ Access road and water supply meet local fire jurisdictional requirements ❑ ❑ 811109 R311.6 Ramps _Inside Ramp 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). ❑ ❑ Outside Ra—n YES NO R311.6.1 Maximum Slope one unit vertical in twelve units horizontal (8.3% slope). ❑ 0 R311.6.2 Landing Requirements: min. 3X3 foot landing at top/bottom, where doors open onto ram s,,and-where:'ramp changes` directions. _ ❑ ❑ :. R311.6.3 Handrails required (on both sides of: ramp: per state licensing requirement WAC 388776-10730) ❑ NO **Guards below are depicted vertically as an example only. l Guard 36" min Less than 4" ADULT FAMILY 1 1 G E r i A W per `?x 06 IRC with 'A(A. ST. A.,AI ENDAEPJ'S i "ALL RAMPS REQUIRE t- 8° IL Q'i`Q 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 hei ht. ❑ ❑ 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 orspecial knowledge or effort. ❑ ❑ 1113115 Stairwa s 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) ❑ . ❑ R311 5.6 Handrails -re' uired;on both sides of..one.riser ormore er.state licensin re uirement 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 if structurally not feasible use type that affix to toilet seat ❑ ❑ AG101 Swimming':Po01,.Spa,_HoitTub `: YES; NO AG105 Must be surrounded lby a barrier that is 48 inches high,, may have doors and or gates that must have audible alarms'when.opened:. . ❑; ❑ AG105.5 EXCEPTION: `S as or hot'tubs with a safet ,cover which complies with ASTM F 1346 ❑ ❑ ❑ PASSED INSPECTOR'S ADDRESS: ❑ CORRECTIONS REQUIRED ❑ PERMIT REQUIRED 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