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REQUEST FOR INSPECTION- Adult Family Home
APPLICATION NUMBER: L 0 "Oyk/
Applicant must complete sections 1, 2, 3, and 4. Application must be complete to be processed.
SITE ADDRESS: ,8t/o9-7 067`9 17-9V1 " �`S L ` ASSESSOR'S TAX/PARCEL ##- 6915-072CO"!V 2200
PROPERTY OWNER NAME:
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)
IMIN :X
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AUG 2 9 2006
BUILDING DEPARTMENT
GTY OF EDMONDS
SECTION 4 DISCLAIMER/SIGNATURE BLOCK
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 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" A4� /141n0 DATE:
XPROPERTY OWNER APPLICANT LICENSEE
PASSED � p C ,,
INSPECTOR: V �(" "�Vk
CORRECTIONS REQUIRED
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PERMIT REQUIRED
DATE: \—
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YES
NO
Home licensed (or applying for license) on or after July 1, 2001
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SLEEPING ROOMS
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Sleeping Room #1 -1 S NSl -1 NS2
Bedroom door is openable from the outside when locked
Closet doors are readily openable from the inside
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Smoke alarm is installed in the bedroom
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Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide)
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Sleeping room window has a maximum sill height of 44"
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Sleeping Room #2 -1 S N S 1 I NS2
Bedroom door is openable from the outside when locked
L✓
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Closet doors are readily openable from the inside
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1
Smoke alarm is installed in the bedroom
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Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide)
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Sleeping room window has a maximum sill height of 44"
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Sleeping Room #3 _] S NSI -1 NS2
Bedroom door is openable from the outside when locked
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^Closet
Closetdoors are readily openable from the inside
Y
Smoke alarm is installed in the bedroom
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Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide)
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Sleeping room window has a maximum sill height of 44"
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Sleeping Room #4 _1 S YNSI I 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)
Sleeping room window has a maximum sill height of 44"
Sleeping Room #5 S NS 1 l NS2
Bedroom door is openable from the outside when locked
I✓
Closet doors are readily openable from the inside
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Smoke alarm is installed in the bedroom
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J
Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide)
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Sleeping room window has a maximum sill height of 14"
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Sleeping Room #6 1 S NS1 -1 NS2
Bedroom door is openable from the outside when locked
L
Closet doors are readily openable from the inside
L
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Smoke alarm is installed in the bedroom
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Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide)
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Sleeping room window has a maximum sill height of 44"
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GENERAL
Bathroom doors are openable from the outside when locked
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Smoke alarms are installed on all levels of the dwelling
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All smoke alarms are audible in all parts of the dwelling upon activation of a single device
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Access road and water supply approved by Fire Department
PASSED � p C ,,
INSPECTOR: V �(" "�Vk
CORRECTIONS REQUIRED
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PERMIT REQUIRED
DATE: \—
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