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Sl ATE OF CALIFOF "7A
IRE SAFETY INSPECTION REQUEST
S . 850 (REV. to -B4)
See Instructions on reverse.
AK ENCY CONTACT'S NAME
TELEPHONE NUMBER
REQUEST DATE
PROGRAM
DSS/COMMUNITY CARE LICENSING
530 895-5033
10/19/06
RCFE
ALUATORS NAME
REQUESTING AGENCY FACILITY NUMBER
REQUEST CODE
205/PAT COFFMAN
045001839
1A
CODES
1. ORIGINAL A. FIRE CLEARANCE
B. LIFE SAFETY
LENSING DEPARTMENT OF SOCIAL SERVICES
2. RENEWAL
AGENCY
ME AND COMMUNITY CARE LICENSING
3. CAPACITY CHANGE
ADDRESS 520 COHASSET ROAD, SUITE 6
4. OWNERSHIP CHANGE
CHICO, CA 95926
5. ADDRESS CHANGE
I
t—
6, NAME CHANGE
7. OTHER
FAX #: (530) 895-5934
AMBULATORY
NONAMBULATORY
BEDRIDDEN
TOTAL CAPACffY
A TY
PREVIOUS CAPACITY
CAPACITY
PREVIOUS CAPACITY
CAPACITY
PREVIOUS CAPACITY
0
O
0
G
CILITY NAME
LICENSE CATEGORY
�,
RCFE
IRS CARE H
S' rREET ADDRESS (Adw/ WWI-)
NUMBER OF BUILDINGS
117 LOWER WYANDOTTE RD.
1
CITY/
`l/
RESTRAINT
ROVILLE, CA 95966 6 —'
NO
F L1TY CONTACT PERSONS NAME ""
NICOLETA ANGHELUTA (530) 534-7996 r 24
CAL CONDITIONS
CLEARANCE /DENIAL CODE
BUTTE COUNTY FIRE DEPARTMENT CODES
FIRE ATTN: FIRE INSPECTION 1. 'IRE CLEARANCE GRANTED
IUTHORITY
2. FIRE CLEARANCE DENIED
NAME AND 176 NELSON AVENUE
ADDRESS OROVILLE, CA 95965-3425 A. EXITS
B. CONSTRUCTION
J C. FIRE ALARM
D. SPRINKLERS
NPECTOR'S NAME (ryW orPbbd) TELEPHONE NUMBER CFIRS NUMBER OCCUPANCY CLASS
E. HOUSEKEEPING
�� / v it )L Fi/�— 1 yL%) i �� 5 ! O �✓ �:� j� F. SPECIALHAZARD
WECTTON DATE WSPECTORS SIGNATURE (ryw or Pdwoo G. OTHER
PLAIN DENIAL OR UST SPECIAL CONDIT16NS
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