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20120822134224337.pdfAPPLICATION AND INSPECTIONCHECKLIST ® 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 � � � / �� 41' 1 � �� `J "' JT � ` ASSESSOR'S TAX/PARCEL# : — — — — — — - - — — — PROPERTY OWNER NAME: DAYTIME PHONE: �1)6) 6 ' 0 ] & 2"" LICENSEE NAME (IF DIFFERENT): DAYTIME PHONE: 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 & ELEVATORS. (USE BACK OF THIS PAPER IF YOU NEED MORE ROOM) 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 1 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 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 officersand employees, upon the accuracy of the information supplied to the jurisdiction as a part of this application. N�A"ME/TITLE: � d ( I �" Po CI � .� � � ,.�� , .. iA, � �� , �.... DATE �� d. � t el 1J PROPERTY OWNER ❑ APPLICANT ❑ LICGENSEE 811109 NAME OF AFH: 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. Type NS2 — where two means of egress do not have stairs to evacuate. SLEEPING ROOMS Sleeping Room #1 ❑ Type S Type NS1 ❑ 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 openable from the outside when locked El 1:1 Sleeping room window has minimum dimensions at least 24" nigh, at least 20" wide (NETOPEN-ABLEAREA OF 5.7 SF **j ❑ **EXCEPT PER R310.1.1: AT -GRADE ESCAPE WINDOWS -(MAY HAVE NET CLEAR OPENING 5 sF ) im m ht of 44" above floor; no steps under window permitted Sleeping room window has a maximum sell height p p ® ❑ Sleeping Room #2 El Type S Type NSI_._ Type NS2. I N®_.. _ _ _El Closet door/s are readily openable from the inside j YES NO ❑ Smoke alarm Is installed m the bedroom vYES_ ❑ Bedroom door is easily and quickly openable from the outside when locked Sleeping room window has minimum dimensions at least 24" high, at least20" wide (NETOPEN-ABLE AREA OF 5.7 SF**) { ❑ *EXCEPT PER R31 0 1 1. AT GRADE ESCAPE WINDOWS (MAY HAVE NET CLEAR OPENING 5 SF) Sleeping room window has a maximum sill height _ _..__._.,._.....�..�..�a p g of 44" above floor; no steps under window permitted mm ❑ Sleeping Room #3 ( ❑ Type S Type NS1 El Type NS2 NO Aq Closet doorls are readily openable from the Inside YEs NO❑ i Smoke alarm is installed In the bedroomEl TYES . W Bedroom door is easily and quickly openable from the outside when locked 0. ❑ 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 windondo_w permitteted ,gym ❑ Sleeping Room #4 El Type S Type NSI Type NS2 YES NO Closet doorls are readily openable from the inside YES 0,, 1 NO ❑ ; Smoke alarm Is Installed In the bedroom l , 91❑ Bedroom door Is easily and quickly openable from the outside when locked I ❑ Sleeping room window has minimum dimensions at least 24" high, at least 20" wide (NETOPEN-ABLEAREA OF 5.7 SFx�.,. s ®� **EXCEPT PER R310.1.1: AT -GRADE ESCAPE WINDOWS -(MAY HAVE NET CLEAR OPENING 5 SF ) ._sill height of 44" above floor, no steps under window permitted Sleeping m window has a maximum ❑ Sleeping Room #5 ❑ Type S ❑Type NSi ❑ Type NS2 YES NO Closet door/s are readily openable from the jrI 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 24" high; at least 20" wide --(NET OPEN -ABLE AREA 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-- ❑ Np ❑ 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 least20"wide—(NET OPEN -ABLE AREA OF5.7SF Wm\ Hµ SY Y10 El **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 ❑ rv❑ GENERAL YES NO Bathroom doors are easily and quickly openable from the outside when locked i ❑ Smoke alarms are Installed on all levels of the dwelling, In each bedroom and common areas 0 ❑ Any smoke alarm must be audible throughout the home when activated _._ ❑ Access road and water supply meet local fire jurisdictional requirements s ❑,,, ❑ 8(1109 �� " - R311.6.1 Maximum Slope one unit vertical in twelve units horizontal � � R311.6.2 Landing Requirements: min. 3X3 foot landing at top/bottom, where doors open onto F] F] ramps, and where ramp changes directions. _�___ K311.6.3 Handrails required (nn WAC 388-76-10730). �� 'l07]0)� | | Ll Outside Ran YES NO R311.6.1 Maximum Slope one unit vertical in twelve units horizontal (8.3% slope). F1 El R311.6.2 Landing Requirements: min. 3X3 foot landing at top/bottom, where doors open onto El FJ R311.6.3 Handrails required (on both sides of ramp: per state licensing requirement WAC 388-76-10730) **Guards below are depicted vertically as an example only. Less than 4" /�uUL/ [t�,m/|L| |/uwf /�noor R311 Means qf_Egress YES NO R311.4.2 Door Type and Size: Side-hinqed not less than 3 feet in width and 6 feet 8 inches in hejqht.,_,_,_, R311.4.4 Type of lock or latch: readily openable from the side from which egress is to be made FJ without the use of a key or special knowledge or effort. R311.5 StairWp YES NO _ys R311.5.3.1 Riser Height: Max riser height shall be 73/4 inches (8 inches in structures built prior to July 1, 2004) El El R311.5.3.2 Tread Depth: Min. tread depth shall be 10 inches. (9 inches in structures built prior to July 1, 2004) n El R311.5.6 Handrails required on both sides of one riser or more (per state licensing requirement WAC 388-76-10730) El El Bars in Bathrooms . YES NO —Grab WAC 388-76-10730 The AFH must install and securely fasten grab bars (not suction cup style) to meet q the needs of residents in: Bathing facilities such as tubs and showers; and Ij On both sides of the toilet (if structurally not feasible use type that affix to toilet seat) E9, o AG101 Swimming Pool, Sgg,_Hot Tub IVA YES NO AG105 Must be surrounded by a barrier that is 48 inches high, may have doors and or gates that must have audible alarms when opened. —AG105.5 EXCEPTION: Spas or hot tubs with a safety cover which complies with ASTM F 1346 El El PASSED F1 CORRECTIONS REQUIRED PERMIT REQUIRED Ij 41 Application and Inspection Checklist developed Association of Building NUcie|o (Wx8m, in cooperation with Department o|Social and Hm|W Somirao (oSHS)for use by both departments and licensors. �� [ = — / 811109