Loading...
20120822150735575.pdfSITE ADDRESS: �� � /� l/ ( �i4A) ASSESSOR'S TAX/PARCEL PROPERTY OWNER NAME: /^' %l. -l../ J� 411(t Mt DAYTIME PHONE LICENSEE NAME (IE DIFFERENT): 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 , 1 e� y �q'✓ lI� REQUEST F INSPECTION- Adult Family Home APPLICATION NUMBER: Applicant must complete sections 1, 2, 3, and 4. Application must be complete to be processed. SITE ADDRESS: �� � /� l/ ( �i4A) ASSESSOR'S TAX/PARCEL PROPERTY OWNER NAME: /^' %l. -l../ J� 411(t Mt DAYTIME PHONE LICENSEE NAME (IE DIFFERENT): 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 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: 'f{ tir' -� �� h A"') � lG�l.,Lt-1 l DATE: "I! PROPERTY OWNER __. APPLICANT YLICENSEE IFS �J; � r 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: 'f{ tir' -� �� h A"') � lG�l.,Lt-1 l DATE: "I! PROPERTY OWNER __. APPLICANT YLICENSEE � YES��[ NO Home |�oosed�vapp�inghx|�after July � � SLEEPING ROOMS -1ensa)onora]u|y1,�0O1 Sleeping O ��1-1S �] NS2 sevvhenlocked Bednmmdoor isopenab|ehnmthe o�N [%101] Oosetd000are readily openab|ehnmthe inside Smoke alarm isin�aUedinthe bedroom B° ] Sleeping room window has aminimum net openab|earea nf5.7d.(mmimumdimensions- z�^mn»;zo^wide) Sleeping room window has a maximum sill height of 44" �` ] Sleeping Rommm��2 O S ��lN8| 3 NS2 Bedroom door isopenab}chnmthe outside vvhonlocked p� � OoseLd000are readily openab|efrom the inside Smoke alarm isinstalled inthe bedroom [1011] Sleeping room window has aminimum net npenab|earea of5.7sf.(mmimumuimmsivns'm^moh;m^�iuo) � e ] Sleeping room window has amaximum sill height of44" n�~ -1Sleepimg0mmmm#3 O S � NSI� 7�S2 Bedroom door isopenab|ehnmthe oubidewhen locked /�^ ] Oosetd000are readily openab}ehnmthe inside IV'] Smoke alarm isinstalled inthe bedroom I~� i 8ecpingroom window has aminimum net openab|earea of5.7sf.(mmimumuimenuoo,m''mox;,o^wmc) iw~ | 8eepingroom window has amaximum sill height of44" IV] Sleeping Rmumm��4 ] S s�l'Sl I NS2 Bedroom door isopenab|efrom the outside vvhenlocked �� ] Closet d000are readily openab|ehnmtheinside the inside |A��h ��^ �T' �i/�N�N��T� Fw/ � Smoke alarm isinstalled inthe bedroom IV | Sleeping room window has a minimum net openable area of 5.7 Sf. (minimum dimensions- 24" high; 20" wide) �V ] Sleeping room window has amaximum sill height of44" �V � ^ Sleeping Room #5 S ] N62 Bedroom door isopenaNefrom the outside when locked |tor | Closet doors are readily openab|efrom the inside Smoke alarm is installed inthe bedroom �~ | Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide) V -1 Sleeping room window has amaximum sill height uf44" [�- ] Sleeping Room #6 ] S NSl J NS2 Bedroom door isopenab|efrom the outside when locked [ -1 Closet doors are readily openab|efrom the inside [ ] Smoke alarm isinstalled inthe bedroom [� l Sleeping room window has a minimum net openable area of 5.7 sf. (minimum dimensions- 24" high; 20" wide)L ] Sleeping room window has amaximum sill height uf44" L � GENERAL Bathroom doors are openab|efrom the outside when locked ] Smoke alarms are installed on all levels ofthe dwelling ] All smoke alarms are audible in all parts of the dwelling upon activation of a single device Access road and water supply approved byFire Department PASSED CORRECTIONS REQUIRED ] PERMIT REQUIRED INSPECTOR: DATE: '