HomeMy WebLinkAbout042-160-068 CF ArchiveSTA OF CALIFORNIA
FiE SAFETY INSPECTION _ST. ~'
see instrucrions on reverse.
S. 0(REV.10-94)
AGE Y CONTACT'S NAME TELEPHONE NUMBER REQUEST DATE ! PROGRAM
EVAL ATOR'S NAME i REQUESTING AGENCY FACILITY NUMBER REQUESTCODE
CODES
IGINAL<nRE CLEARANCE
LI ENSING 2. RENEWAL B. LIFE SAFETY
�GENCY
N ME AND �� 3. CAPACITY CHANGE
A DRESS j �� 4. OWNERSHIP CHANGE
D�
5. ADDRESS CHANGE
6. NAME CHANGE
7. OTHER
AMBULATORY NONAMBULATORY BEDRIDDEN TOTAL CAPACITY
CAF ACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY
s
i
1 i
FA ILITY N E LICENSE CATEGORY
STI tEETADDRESS ( alLowban) NUMBER OF BUILDINGS
CIlly RESTRAINT
FA CILRY CONTACT PERSON'SfNAME HOURS
CONDITIONS
TO BE COMPLETED BY INSPECTING AUTHORITY
CLEARANCE IDENIAL CODE
�-- CODES
FIRE FIRE CLEARANCE GRANTED
UTHORITY ,. ���%�/`- ���%� 7-Cer-
NAME AND 2. FIRE CLEARANCE DENIED ADDRESS 1 76 ��L ��� ��� A. EXITS
B. CONSTRUCTION
i � 1
` C. FIRE ALARM
z A4
SPECTOR'S NAME (TypedorPrinted) TELEPHONE NUMBER CFIRS NUMBER OCCUPANCYCLASS D D. SPRINKLERS
E. HOUSEKEEPING
d.�
F. SPECIAL HAZARD
NSPECTION DATE INSPECTOR'S SIGNATURE ypedorPrinted) G. OTHER
LAIN DENIAL OR LIST SPECIAL CONDITIONS
of�
00-01
/�,% OF7V 15;�( 7� -div 1_
.+c