20120822144239875.pdfs s
REQUEST FOR INSPECTION- Adult Family Home
Applicant must complete sections 1, 2, 3, and 4. Application must be complete to be UMBER: 0V-52—
° processed.
SITE ADDRESS:
ASSESSOR'S TAX/PARCEL #.2%10L/ / /,
• V
PROPERTY OWNER NAME: r ° °
��� �
� l I (� �i Iii
LICENSEE NAME (IF oIFFERENT): DAYTIME PHONE: _
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)
I certify under penal , •
ty of perjury that the information furnished b
the owner of the above premises to request inspection for and operate an
application to the D Y me is true and correct to the best of my knowled e
location. Department of Social and Health Services and Adult Family Home at this location. I fu g ' and that I am authorized by
I further agree to hold harmless the jurisdiction rther certify
ys' fees incurred in the investigation of such Bairn the )urisdidion for the appropriate licenses) to condu
attorneys' conducting such inspections ai my request as to any Brim
(including oasts have made
jurisdiction, but Only). which may be made b au � such business at this
information b where such claim arises out of the reliance of
Y y person, including the undersigned, and filed against the and
supplied to the the jurisdiction, including Jurisdiction as a p rt d this a 9 its officers and employees, upon the accuracy NAME/TITLE- application-
� � of the
-) PROPERTY NER- APDATE:
PLICAN r L LICENSEE
•
YES NO
Home licensed (or applying for license) on or after July 1, 2001
SLEEPING ROOMS
I
Sleeping Room #1 ` ] S NS1 ;j NS2
Bedroom door is openable from the outside when locked /'
/ I
Closet doors are readily openable from the inside
c> J
1�
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 #2 ] 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
-1
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 #3 D S - NSI NS2
Bedroom door is openable from the outside when locked
i
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 ] 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 -1 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
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"
L.
Sleeping Room #6 1
I S — NS] ]NS2
Bedroom door is openable from the outside when locked
L
Closet doors are readily openable from the inside
I 1
Smoke alarm is installed in the bedroom
1
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"
L J
GENERAL
Bathroom doors are openable from the outside when locked
>< —�
Smoke alarms are installed on all levels of the dwelling
X i
All smoke alarms are audible in all parts of the dwelling upon activation of a single device
X
Access road and water supply approved by Fire Department
X
PASSED _ CORRECTIONS REQUIRED PERMIT REQUIRED
INSPECT DATE:
A F ��IL r /ivs�r� ��6rL � !97