HomeMy WebLinkAbout015-310-018 CF ArchiveTATE OF CALIFORNIA
IRE SAFETY INSPECTION REQUEST
TD. 850 (REV.1 0-94) See instructions on reverse.
GENCYCONTACT'SNAME
TELEPHONENUMBER
REQUESTDATE
PROGRAM
CDSS/COMMUNITY CARE LICENSING
530 895-5033
12/7/04
14
VALUATOR'S NAME
REQUESTING AGENCY FACILITY NUMBER
AMPELLI, STACEY FAMILY CHILD CARE HOME
REQUESTCODE
ERIN MOORS
045404128
4 COTTAGE AVENUE
3A
C
RESTRAINT
HICO
CODES
DEPARTMENT OF SOCIAL SERVICES
HOURS
1. ORIGINAL A. FIRE CLEARANCE
LICENSING
AGENCY COMMUNITY CARE LICENSING
2. RENEWAL B. LIFE SAFETY
NAME AND 520 COHASSET ROAD, SUITE 6
3. CAPACITY CHANGE
ADDRESS CHICO, CA 95926
4. OWNERSHIP CHANGE
5. ADDRESS CHANGE
L
6. NAME CHANGE
7. OTHER
AMBULATORY
NONAMBULATORY
BEDRIDDEN
TOTAL CAPACITY
CAPACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY
14 8 0 0 0 0
14
CILITY NAME
LICENSE CATEGORY
AMPELLI, STACEY FAMILY CHILD CARE HOME
810
S rREETADDRESS (Actual Location)
NUMBER OF BUILDINGS
4 COTTAGE AVENUE
C
RESTRAINT
HICO
NONE
F CILITY CONTACT PERSON'S NAME
HOURS
TACEY ZAMPELLI (530) 899-7791
DAYS
GONDMONS
TO BE :COMPLE. ,ED BY ;INS : E
T P CTlNG. AUTH.RITY
CLEARANCE/DENIAL CODE
CODES
FIRE 1. IRE CLEARANCE GRANTED
AUTHORITY
AME AND CDF BUTTE COUNTY FIRE DEPT. 2. FIRE CLEARANCE DENIED
DDRESS ATTN: STEVE FOWLER A. EXITS
176 NELSON AVE.
�OROVILLE, CA 95965 B. CONSTRUCTION
C. FIRE ALARM
INSPECTOR'S NAME (Typed orPfinled) TELEPHONENUMB CFIRS NUMBER OCCUPANCY CLASS D. SPRINKLERS
e &X6
E. HOUSEKEEPING
r Q�
�✓ (00) ,�(JCj QA0 F. SPECIAL HAZARD
IN PE ION DAT INSPECTOR'S SIG URE(TypedorPrinted G. OTHER
Alqu.-M-0- I
ND IAL OA LIST SPECIAL CONDITIONS
DECRECEIVED
15 2004
Community Care Licensing