HomeMy WebLinkAbout025-350-031PAULIE' S IDAY 'CARE`
28, Sun Cloud Cirlce
O'roville;;
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y
(�\1 i [„M.l C
f "vofe 0-pir /^,vsoa L 10 ao6e� a-*-� -Ale� J/�j
COUNTY OF BUTTE- DEPARTMENT OF DEVELOPMENT SERVICES -BUILDING DIVISION
7 Coun Center Drive - Oroville, California 95965 - Telephone (916) 538-7541 PERMIT NO.
(Rev. 12/96) ,.� APPLICATION AND PERMIT
ASSEssGS3,�gcEyt,y�MB�T, 031
CHARD
ZONING
BUILDING PERMIT
OWNER
RICHARD DIXON
TELEPHONE
SO. FT. OCC. BUILDING VALUATION
-3 5 HOT mnp
1,225
OWNERS 8LIS
U1�CLOUD CIRCLE, OROVILLE
cG��PRO TEC RESTORATION & CONSTR. INC. 619_TELEPHONE4630469
`G GO IEAdRs AVE, LEMON GROVE 91969 19 286-4406
CONSTRUCTION LENDER
Fireplace
LENDER'S MAILING ADDRESS
Total Valuation $ 1,225
ARCHITECT OR ENGINEER
LICENSE NO.
Filing Fee $
20.00
Permit Fee $
31.00
ARCHITECT OR ENGINEERS MAILING ADDRESS
Plan Checking Fee $
BUILDING ADDRESS
28 SUNCLOUD CIRCLE, OROVILLE
Energy Plan Checking Fee $
$
PERMIT FEE $
51.00
LOT NO.
SUBDIVISIONS NAME
PARCEL MAP
PLUMBING PERMIT
Filing Fee 20.00
Each Trap
7.00
USEOFSTRUCTURE
SF CXXDuplex ❑ Mobilehome ❑ Other
SPECIFY
Solar or heat pump water heater
23.00
Water piping
15.00
Each gas water heater or vent
15.00
TYPE OF WORK
New ❑ Addition ❑ Remodel ❑ Utilities ❑ Installation ❑ Other XX
HOT MOP REROOF
Describe Work:
Gas piping system 1 - 5 outlets
15.00
sewer
15.00
—Building
Mobile Home I S I G I W
@20.00
PERMIT FEE $
ELECTRICAL PERMIT
Fling Fee 20.00
Main Service ocn oa mss
23.00
_71ICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that 1 am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Business and Professions Code,
and my license is in full force and effect.
License Class Lic. No.
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors License
Law for the following reason:
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale.
❑ I, as owner of the property, am exclusively contracting with licensed contractors
to construct the project.
❑ 1 am exempt under Sec. Business and Professions Code for this .
reason
Main Service 200A TO ,000A
46.00
NEW CONST. DWELLING UP.
OR ADDNS. ( 8 ACC. BLD S.
50
50SO.
3.5¢x;
NE RES"DT MULTI.00IRCUITS UrLET
97._50
POWER APPARATUS
8 SINGLE OUTLET CIR.
Ex. Occup. OUTLET OR FIXTURES
20 (jP ,.00
BAL- @ .50
ED
Ex. Occup. GFlxur rs R oOEA
5.00
Temporary Service
23.00
Mobile Home Facilities
20.00
Misc. Wiring
23.00
PERMIT FEE $
WORKERS' COMPENSATION DECLARATION
1 hereby affir under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
❑ 1 have and will maintain workers' compensation insurance, as required by Section
3700 of the Labor Code, for the performance of work for which this permit is issued.
My workers' compensation insurance carrier and policy number are:
Carrier
MECHANICAL PERMIT Fling Fee 20.00
Heating
Cooling
Hood
6.50
Ventilation
PERMIT FEE $
Policy Number
(The above sections need not be completed if the permit is for work of a valuation
of one hundred dollars ($100) or less.)
❑ 1 certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to workers'
compensation laws of California, and agree that if I should become subject to the
workers' compensation provisions of section 3700 of the Labor Co, I shall
forthwith comply with those provisions.
_ ate — —_
Signature of Applicant - ❑ Owner ❑ Contractor ❑ Agent
An OSHA permit is required for excavations over 60" deep and demolition or construction
of structures over 3 stories in height.
Mobile Home Installation Fee $
Energy Inspection Fee $
OCC
CONST. TYPE
TOTAL FEE $ 51.00
HA2.
I D. FEES IMP
I FLOOD
CDF
;Z;C7 FD
I HD
ISSUE
This permit is hereby issued under the applicable provisions
of the Butte County Code and/or Resolutions to do work
indicated above for which fees have been paid.
By Date
PERMIT EXPIRES ON
ate
ReceiptNo.
WHITE-D.D.S.-B.D. CANARY -ASSESSOR PINK -INSPECTOR GOLDENROD -APPLICANT
Paulie's Day Care ®I D ,, 1dYl
Oroville, CA 9596 R
Attn: Pauline Dixon
August 30, 1991
RE: Day Care Fire Inspection
. (A.P. 36-25-31)
The Department of Social Services Community Care Licensing in Chico has made
a request to this office for a fire safety inspection of your proposed day care
facility (maximum capacity, 12) at 28 Sun Cloud Circle in Oroville.-
Your property is located within an ARMH2.5 zone which requires a use permit
from the Butte County Planning Department prior to business operation. Please
contact them at '(916)538-7601 between 10:00a.m. and 3:p.m. for information on
how to proceed.
When you have made the application for the use permit and paid the
appropriate fees, you may apply to this office for a Special Inspection for the
fire inspection.
For the Special Inspection we will require a plot plan showing the building
location on the property, a floor plan showing room uses, windows, doors,
mechanical equipment etc., and the appropriate fee and the application signed
by the property owner.
After we make the Special Inspection, we will write a letter advising you of
any improvements and building permits that may be required.
We will not notify the Department of Social Services of any clearances until
you have been issued a use permit and complied with both the Planning and Building
Department requirements.
Should you have any questions concerning this matter, please contact this office.
JFG:dms
cc: Department of Social Services
Planning Department
Yours very truly,
William Cheff
Director of Public Works
t 3 6Fig t 9
J.F. Glander
Manager, Building Inspection
STATE FIRE MARSHAL COPY DISTRIBUTION: SEE REVERSE OF COPIES 2 AND 5 FOR
CIRF CACCTV IIUCD=PTInkI 0CnI1CCT I-A--STATF FIRF MARSHAI INSTRUCTIONS FOR COMPLETION
2 -FIRE AUTHORITY
1. REQUEST DATE
PROGRAM
STD 850 (REV. 8/86) 4 -5 -LICENSING AGENCY
12.
3. AGENCY CONTACT
4. TELEPHONE NO.
5. EVALUATOR
DSS/COMMUNITY CARE LICM.SING
1
(916) 895-5033
0105/P. SEXTON
6. SFM REGION
SFM I.D. NO.
8. REQUESTING AGENCY FACILITY NO.
9. REOUEST CODE
17.
041373717
3/A
CODES
1. ORIGINAL A. FIRE CLEARANCE
2. RENEWAL B. LIFE SAFETY
DEPARTMENT OF SOCIAL SERVICES
3. CAPACITY CHANGE
4. OWNERSHIP CHANGE
f0. AGENCY COMMUNITY CARE LICJI IN G
NAME
520 COHA'+SSET ROAD, SUITE6
AND CHI CO, CA 95926
ADDRESS
J
S. ADDRESS CHANGE
6. NAME CHANGE
7. OTHER US NAME
DATE OF ORIGINAL REQ.
11. AMBULATORY - NONAMBULATORY
TOTAL CAP.
DATE OF LAST FIRE CLEARANCE
CAPACITY
AGE RANGE (YEARS)
PREVIOUS CAPACITY
AGE RANGE (YEARS)
PREVIOUS
12
TO 18 1 18 TO65 AND
X 65 OVER
CAPACITY
0
TO 18 18 TO 65 AND
65 OVER
CAPACITY
12
19. FACILITY
CODE 13/FDC
12. FACILITY NAME
13. NO. SLOGS
CODES
PAULIE' S DAY CARE
1
1. GACH 7. ICF/OT
2. GACH/R 8. ICF/DD
14. STREET ADDRESS (ACTUAL LOCATION)
P.O. BOX
15. RESTRAINT
28 SUN CLOUD CIRCLE
. NONE
3. SH 9. ADHC
4. APH 10. CLINIC
CITY
21P CODE
16. HOURS:=:
OROVILLE, CA
95965
6-8
5. PHF 11. JAIL
6. SNF 12. ICF/DDN
17. FACILITY CONTACT PERSON
TELEPHONE NO.
16A. SPECIAL
PAULINE DIXON
(916) 532=1790
13. OTHER
TO BE COMPLETED BY
INSPECTING AUTHORITY
18. FIRE ATT: DAVID PURVIS
26 CLEARANCE
CODE
AUTHOR BUTTE COUNTY BUILDING DEPARTMENT
CODES
NAME 7 COUNTY CENTER DRIVE
AND OROVILLE, CA 95965
ADDRESS
J
1. FIRE CLEAR, GRANTED
2. FIRE CLEAR, DENIED
3. FIRE CLEAR, WITHHELD
27. DENIAL
CODE
TO BE COMPLETED BY INSPECTING AUTHORITY -
CODES
21. INSPECTOR'S NAME
TELEPHONE NO.
22. CFIRS
23. T-19 OCC.
- -
ID NO.
CLASS
1. EXITS
2. CONSTRUCTION
3. FIRE ALARM
24. INSP. DATE
25. INSPECTOR'S SIGNATURE
-
1
4. SPRINKLERS
5. HOUSEKEEPING
28. EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS
6. SPECIAL HAZARD
7. OTHER.
-
STATE FIRE MARSHAL USE ONLY
20. REGION. DEPARTMENT. OF SOCIAL SERVICES
OFFICE COMMUNITY CARE LICENSING - -
AND 520 COHASSET ROAD, SUITE 6
ADDRESS L CHICO, CA 95926
STATE FIRE MARSHAL COPY DISTRIBUTION: SEE REVERSE OF COPIESF2 AND 5 FOR
CInC CACCTV IwICCC^TIAAI ncf%l lCCT .1-'i-QTAT9: FIRE nAeacuel - INSTRUCTIONS FOR COMPLETION
u>IL. vr%g 16- 1 1 nv.�rw I 1w1v _ ...._ ....... ...._
' 2 -FIRE AUTHORITY
1. REOUEST DATE
PROGRAM
STD 850 (REV. 8•/86) ' 4 -5 -LICENSING AGENCY
Q X77 X01
I2.
3. AGENCY CONTACT -
4. TELEPHONE NO.
5. EVALUATOR
DSS/COMMUNITY CARE LICESNING-
(916) 895-5033
0105/P. -SEXTON
6. SFM REGION
7. SFM I.D. NO.
8. REQUESTING AGENCY FACILITY NO.
9. REQUEST CODE
041373717
3/A
CODES
1.. ORIGINAL A. FIRE CLEARANCE`t'
2. RENEWAL B. LIFE SAFETY
- -
F-�
�7�Ap SERVICES
Dr,rtiL�r'�,ENT OF SOCIAL
VL�ICES++NIN+TGj
3. CAPACITY CHANGE
4. OWNERSHIP CHANGE
TSERVI_CES
1O. AGENCY COMMUNITY1 CARE
S. ADDRESS CHANGE
NAME -C2O COHASSET ROAD, j SUITE6
AND � a1t V ` `r'
CHICO, CA X5926
ADDRESS � I �
J
6. NAME CHANGE
PREVIOUS NAME
7. OTHER
DATE OF ORIGINAL REQ. -
11. AMBULATORY - -
-
NONAMBULATORY
TOTAL CAP.
DATE OF LAST FIRE CLEARANCE
CAPACITY
AGE RANGE (YEARS)
PREVIOUS
CAPACITY
AGE RANGE (YEARS)
PREVIOUS
12
TO 18 1 18 TO 65 AND
X 65 OVER
. CAPACITYCAPACITY
- '
O
TO 18 1 18 TO 65 AND
65 OVER
12
19. FACILITY p -
CODE 13/FDC
12. FACILITY NAME
PAULIE' S DAY CARE
13. NO. BLDGS
1
CODES
1. GACH 7. ICF/OT
2• GACH/R 8. ICF/DD
3• SH' 9. ADHC
4. APH 10. CLINIC
5. PHF 11. JAIL
6• SNF 12. ICF/DDN
13. OTHER
14. STREET ADDRESS (ACTUAL LOCATION) -
28 SUN . CRUD CIRCLE
P.O. BOX -
15. RESTRAINT
NONE
CITY
OROVILLE, CAf
ZIP CODE
95965
16. HOURS ,••
6-8
17. FACILITY CONTACT PERSON;
PAULINE DIXON
TELEPHONE NO... � y � �
(916)-532-1790
16A. SPECIAL
TO BE COMPLETED BY
INSPECTING AUTHORITY
r�+�� �-
18. FIRE A11 s. DAVID PURVIS -
AUTHOR BUTTE COUNTY BUILDING DEPARTMENT e
26. CLEARANCE
CODE
CODES
NAME .7 COUNTY RENTER DRIVE
AND OROVILLE; CA 95965 -
ADDRESS
1. FIRE CLEAR, GRANTED
2. FIRE CLEAR, DENIED
'3. FIRE CLEAR, WITHHELD
-
27. DENIAL
CODE
TO BE COMPLETED BY INSPECTING, AUTHORITY ...._ '
'• CODES
21. INSPECTOR'S NAME
TELEPHONE NO.
22. CFIRS
23. T-19 OCC.
-
'
ID NO.
CLASS
1. EXITS
2. CONSTRUCTION
3. FIRE ALARM
24. INSP. DATE
25. INSPECTOR'S SIGNATURE -
4. SPRINKLERS
5. HOUSEKEEPING
28. EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS - -
6. SPECIAL HAZARD
7. OTHER
STATE FIRE MARSHAL USE ONLY
20. REGION. F REPARRIMT. OF SOCIAL SERVICES
OFFICE (&- OMMUNITY- CARE LICENSING
.
AND 520 COHAMT ROAD, SUITE 6
_
ADDRESS L CHICO, CA 95926
INSTRUCTIONS
This form is designed for use with a window envelope. To use, fold at marks indicated in the left margin. .
Licensing or Requesting Agencies --Complete the following 20 sections on this form
before submitting it to the State Fire Marshal
1. REQUEST DATE. Enter the date request was
prepared.
2. PROGRAM. Licensing agency use. y
3. AGENCY CONTACT, 4. TELEPHONE NO.,
5. EVALUATOR. Enter the name and telephone
number of agency contact person.
6. SFM REGION. Insert one of the following 3 numbers
for the SFM Regional Office in whose area the facility
is located:
350 Coastal, 330 Northern, 370 Southern.
7. SFM ID NO. This is the SFM Identification Number
and initially will be assigned by the State Fire
Marshal. Licensing Agency—Insert this number on all
clearance requests subsequent to the initial request.
S. REQUESTING AGENCY FACILITY NO. This is the
file number assigned by the licensing agency.
9. REQUEST CODE. Use the seven codes shown and
insert the appropriate number in the box following
"Request Code". If NAME CHANGE, please list
previous name. Insert date of original request when
request is other than an original.
10. AGENCY NAME AND ADDRESS. Enter the name
and address of the licensing facility requesting the
inspection.
11. AMBULATORY—NON-AMBULATORY.
Capacity: Insert, in the appropriate section, the
12. FACILITY NAME. Insert the name of the facility as
it will appear on the license. List identifying sub name
if known (i.e., Hacienda Corp/Medina Lodge).
13. NO. BLDGS. Insert the total number of buildings to
be used for housing of the occupants covered by the
license.
14. ADDRESS. Insert street address and city only. A
post office box is not acceptable as only location.
15. RESTRAINT.' Indicate if physical restraint (locked
in a room or the building is to be used in the housing
of the occupants.
16. HOURS Indicate the number of hours the
occupants are housed at the facility (less than 24 or
24+).
16a. SPECIAL. Use to designate persons who are
determined to be non-ambulatory for .reasons other
than a physical handicap.
17. FACILITY CONTACT PERSON—TELEPHONE
NO.. Indicate the name and telephone number of the
responsible individual at the facility to be contacted
by the fire authority.
18. FIRE AUTHOR, NAME AND ADDRESS. Insert the
name and address of the fire authority where the
facility is located.
19. FACILITY CODE. (1) General Acute'Care Hospital
(GACH), (2) General Acute Care Hospital/ Rehab
(GACH/R), (3) Special Hospital (SH),. (4) Acute
Psychiatric Hospital (APH), (5) Psychiatric Health
Facility (PHF), (6) Skilled Nursing Facility (SNF),
(7) Intermediate Care Facility/Other (ICF/OT),
(8) Intermbdiate . Care :Facility /Developmentally
Disabled Habilitative (ICF/DDH), (9) Adult Day
Health. Care (ADHC), (10) Clinic, (11) Jail,
(12) Intermediate Cara Facility/ Developmentally
Disabled Nursing (ICF/DDN), or (13) Other.
20. REGION, OFFICE AND ADDRESS. Insert the name
and address of the State Fire Marshal Regional
Office in whose area the facility is located.
FIRE AUTHORITY CONDUCTING THE INSPECTION -COMPLETE THE FOLLOWING:
21. INSPECTOR'S NAME. Print the initial of the in-
spector's first name and full last name; insert the
telephone number where the inspector may be con-
tacted.
22. CFIRS ID. NO. Insert the fire department's number
assigned by CFIRS.
23. TITLE 19 OCC. CLASS. Use Title 19 occupancy
classifications and insert the occupancy determined
by the inspector.
24. INSP. DATE. Enter the actual date of the in-
spection.
25. INSPECTOR'S SIGNATURE. To be signed by
inspA^tor conducting the inspection.
26. CLEARANCE CODE. Use the three codes shown
and insert the appropriate number in the box follow-
ing "Clearance Code".
NOTE: If Code 2 (Denied) or Code 3 (Withheld) is used, explain.
27. DENIAL CODE. Use only the seven codes shown
and insert the appropriate number in the box follow-
ing "Denial Code". If No. 7 "Other" is used, explain
at Item 28.
NOTE: Fire Clearance cannot be denied for other than lack of confor-
mance with the provisions of Title 19.
28. EXPLAIN DENIAL. If Clear4r,:;e Code No. 2 or 3 is
Used, briefly explain reason. This space is also to be
used to explain Denial Code item noted.
86 96650
capacity of licensed ambulatory or non- -
ambulatory occupants covered by this
request.
Age
Indicate the age range of the licensed
Range:
occupants
Previous
If request is for renewal or capacity
Capacity:
change, insert capacity of previous
clearance.
Total
Show total licensed capacity. If the facili-
Capacity:
ty is intended to house part ambulatory
and part non-ambulatory, show the total
of the two types of occupants.
12. FACILITY NAME. Insert the name of the facility as
it will appear on the license. List identifying sub name
if known (i.e., Hacienda Corp/Medina Lodge).
13. NO. BLDGS. Insert the total number of buildings to
be used for housing of the occupants covered by the
license.
14. ADDRESS. Insert street address and city only. A
post office box is not acceptable as only location.
15. RESTRAINT.' Indicate if physical restraint (locked
in a room or the building is to be used in the housing
of the occupants.
16. HOURS Indicate the number of hours the
occupants are housed at the facility (less than 24 or
24+).
16a. SPECIAL. Use to designate persons who are
determined to be non-ambulatory for .reasons other
than a physical handicap.
17. FACILITY CONTACT PERSON—TELEPHONE
NO.. Indicate the name and telephone number of the
responsible individual at the facility to be contacted
by the fire authority.
18. FIRE AUTHOR, NAME AND ADDRESS. Insert the
name and address of the fire authority where the
facility is located.
19. FACILITY CODE. (1) General Acute'Care Hospital
(GACH), (2) General Acute Care Hospital/ Rehab
(GACH/R), (3) Special Hospital (SH),. (4) Acute
Psychiatric Hospital (APH), (5) Psychiatric Health
Facility (PHF), (6) Skilled Nursing Facility (SNF),
(7) Intermediate Care Facility/Other (ICF/OT),
(8) Intermbdiate . Care :Facility /Developmentally
Disabled Habilitative (ICF/DDH), (9) Adult Day
Health. Care (ADHC), (10) Clinic, (11) Jail,
(12) Intermediate Cara Facility/ Developmentally
Disabled Nursing (ICF/DDN), or (13) Other.
20. REGION, OFFICE AND ADDRESS. Insert the name
and address of the State Fire Marshal Regional
Office in whose area the facility is located.
FIRE AUTHORITY CONDUCTING THE INSPECTION -COMPLETE THE FOLLOWING:
21. INSPECTOR'S NAME. Print the initial of the in-
spector's first name and full last name; insert the
telephone number where the inspector may be con-
tacted.
22. CFIRS ID. NO. Insert the fire department's number
assigned by CFIRS.
23. TITLE 19 OCC. CLASS. Use Title 19 occupancy
classifications and insert the occupancy determined
by the inspector.
24. INSP. DATE. Enter the actual date of the in-
spection.
25. INSPECTOR'S SIGNATURE. To be signed by
inspA^tor conducting the inspection.
26. CLEARANCE CODE. Use the three codes shown
and insert the appropriate number in the box follow-
ing "Clearance Code".
NOTE: If Code 2 (Denied) or Code 3 (Withheld) is used, explain.
27. DENIAL CODE. Use only the seven codes shown
and insert the appropriate number in the box follow-
ing "Denial Code". If No. 7 "Other" is used, explain
at Item 28.
NOTE: Fire Clearance cannot be denied for other than lack of confor-
mance with the provisions of Title 19.
28. EXPLAIN DENIAL. If Clear4r,:;e Code No. 2 or 3 is
Used, briefly explain reason. This space is also to be
used to explain Denial Code item noted.
86 96650
18. FIRE F ATT; DAVID
PiavIS
AUTHOR BUTa'COUID•MIEWNG DEPARTMENT.
-
NAME 7 COUNTY CENTER DRIVE .
AND OROVILLE-, CA 95965
ADDRESS L
NAME
J
TO BE COMPLETED BY INSPECTING AUTHORITY
TELEPHONE NO. - 22. CFIRS
ID NO. -.
24. INSP. OATE 12S. INSPECTOR'S SIGNATURE
28. EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS .. -
y.:
20. REGION. - F DEPARTMENT:. OF SOCIAL SERVICES
OFFICE ,�CO:+It�IUNITY'CARE,LICENSING
AND 520(aCOHASSET ROAD, SUITE 6 -
ADDRESS CHICO, CA 95926
J
ti
23. T-19 OCC.
CLASS
26. CLEARANCE
CODE
CODES
1. FIRE CLEAR, GRANTED
2. FIRE CLEAR, DENIED
3. FIRE CLEAR, WITHHELD
27. DENIAL
'CODE
CODES
1. EXITS
2. CONSTRUCTION
3. FIRE ALARM t
4. SPRINKLERS
5. HOUSEKEEPING
6. SPECIAL HAZARD
7. OTHER
STATE FIRE MARSHAL USE ONLY -
STATE FIRE MARSHAL COPY DISTRIBUTION: SEE REVERSE OF COPIESt2 AND 5 FOR
FIRE SAFETY INSPECTION REQUEST 1 -3 -STATE FIRE MARSHAL INSTRUCTIONS FOR COMPLETION
2 -FIRE AUTHORITY DATE PROGRAM
FIREQUEST 12.
STD850(REV.8.06) 1 4 -5 -LICENSING AGENCY R/77/Q1
3. AGENCY CONTACT ,
4. TELEPHONE NO.
5. EVALUATOR'
DSS/C0 IUNITY CARE LICESNING'
(916) 895-5033
0105/P. SEXTON
6. SFM REGION
7. SFM I.D. NO. -
B. REQUESTING AGENCY FACILITY NO.
9. REQUEST CODE
041373717
3/A
- + y
CODES
- - -_
1. ORIGINAL A. FIRE CLEARANCE
2: RENEWAL B. LIFE SAFETYf.
F_
�
3. CAPACITY CHANGE
4. OWNERSHIP CHANGE
F! DEPARTMENT OF SOCIAL SERVICES
10. 'AGENCY
Cjy
1J • IUNITY CARE .LICES;N,-I(•rNG}
5. ADDRESS CHANGE
6. NAME CHANGEPREVIO
NAME.` - ^520,�COHASSET ROAD, MI -T- E6", -
_
AND - CHICON CA 9-5926- _
W lid `jGV
ADDRESS e
OTHERUS'NAME
7. OTHER
�
'
DATE OF ORIGINAL REQ.
^
11. AMBULATORY:. -
NONAMBULATORY
TOTAL CAP.
DATE OF LAST FIRE CLEARANCE
3.,. ..,, -- - - +•r
'CAPACITY
AGE RANGE (YEARS)
- PREVIOUS
CAPACITY
AGE RANGE (YEARS)
PREVIOUS
.TO 18 IB TO AND
CAPACITY
-
TO 18 18 TO AND
CAPACITY
19. FACILITY w
12
165
<, 65 OVER
0
165
65 OVER
1
7 2
-CODE -; 13/PDC 1
}
12. FACILITY NAME - -
,13. NO.. BLOG_S
CODES
PAULIE' S DAY CARE
1
1. GACH 7. ICF/OT
2. GACH/R 8. ICF/DD
14. STREET ADDRESS (ACTUAL LOCATION)
P.O. BOX
15. RESTRAINT
28 SUN CLOUD CIRCLE
NONE
3. SH 9. ADHC
a.*
APF 11. CLINIC
CITY -
ZIP CODE
16. HOURS ""
OROVILLE, CA,�
95965.
6-8
5. PHF . . 11. JAIL
^6, SNF 12. ICF/DDN
17. FACILITY. CONTACT PERSON } r`,'°'0'0i .TELEPHONE:
-NO ^ - '� '- ^-
16A: SPECIAL
PAULINE DIXON
(916).532-1790
�-
13. OTHER
-
TO BE COMPLETED BY
INSPECTING AUTHORITY
18. FIRE F ATT; DAVID
PiavIS
AUTHOR BUTa'COUID•MIEWNG DEPARTMENT.
-
NAME 7 COUNTY CENTER DRIVE .
AND OROVILLE-, CA 95965
ADDRESS L
NAME
J
TO BE COMPLETED BY INSPECTING AUTHORITY
TELEPHONE NO. - 22. CFIRS
ID NO. -.
24. INSP. OATE 12S. INSPECTOR'S SIGNATURE
28. EXPLAIN DENIAL OR LIST SPECIAL CONDITIONS .. -
y.:
20. REGION. - F DEPARTMENT:. OF SOCIAL SERVICES
OFFICE ,�CO:+It�IUNITY'CARE,LICENSING
AND 520(aCOHASSET ROAD, SUITE 6 -
ADDRESS CHICO, CA 95926
J
ti
23. T-19 OCC.
CLASS
26. CLEARANCE
CODE
CODES
1. FIRE CLEAR, GRANTED
2. FIRE CLEAR, DENIED
3. FIRE CLEAR, WITHHELD
27. DENIAL
'CODE
CODES
1. EXITS
2. CONSTRUCTION
3. FIRE ALARM t
4. SPRINKLERS
5. HOUSEKEEPING
6. SPECIAL HAZARD
7. OTHER
STATE FIRE MARSHAL USE ONLY -