HomeMy WebLinkAboutFAI15-0038 Fire Annual Inspection ArchiveButte County Fire Department
California Department of Forestry and Fire Protection
Fire Prevention Bureau (D176 Nelson Avenue, Oroville, CA 95965
FIRE530-538-7888/530-538-2105(fax)
E
Fire Safety Inspection
Business Address:
Business Name:
10.
Owner/Manager:
Bus:
Other:
Other Contact:
Bus:
Other:
Building Owner:
Bus:
Other:
Address:
Fire alarms stem defective
Occ. Class:
AN INSPECTION OF YOUR FACILITY REVEALED THE FOLLOWING:
1.
Fire extinguishers: required, service due
10.
Exit(s): obstructed, inadequate
2.
Extension cords: Excessive use, defective
11.
Exit sign(s): required, illumination, photo luminescent
3.
Excessive rubbish, trash, debris
12.
Exit sign lights: obstructed, defective
4.
Fire alarms stem defective
13.
Exit lighting: required, defective
5.
Sprinkler system: service required, defective
14.
Heating system: defective appliance, flue combustibles
6.
Kitchen hood ext. system: service due
15.
Wiring: exposed, damaged connectors, etc.
7.
Fire walls, ceilings, fire doors, draft stops
16.
Address posted and visible from road
8.
Smoke detectors: required, defective
17.
Other
9.
Fire drill log checked Yes ❑ No ❑
18.
Other type of inspection — State below
DETAILED EXPLANATION AND CORRECTIONS: CORRECTED:
ate:
Discussed with:
Signed:
(Print)
�attalion
Inspecting Officer:
1 2 3 4 'S 6 7
Station: FPB
y order of the Fire Chief: You are hereby notified to correct all violations immediately or show cause why you should not be
quired to do so. A re -inspection will be conducted on . Willful failure to comply with this notice is a
isdemeanor. Violations that are not corrected immediately and/or remain after the re -inspection may be processed as a criminal
ffense. Thank you for your assistance and cooperation in minimizing the fire and life loss in our community. (H & S sec. 13112)
White Copy — Station File Yellow Copy — Re-inspect/business Pink Copy — Business ❑ Check when sent to prevention
TATE OF CALIFORNIA
IRE SAFETY INSPECTION REQUEST -
See instructions on reverse.
TD. 850 (REV. 10-94)
AGENCY CONTACT'S NAME :TELEPHONE NUMBER
REQUEST DATE PROGRAM
CDSS/COMMUNITY CARE LICENSING 530 ) 895-5033
9/16/08 CCL
___... _._._.........__ ....__ _.........._
_..__.._.._._.__...._.._..._.__ ..._ _ ........_._ ..._... _ ._..__._... _... _...._.... __.......... _ __....._ _... _........_._.._ __....._._ ._ ........_.. _._...............................__ .........
VALUATOR'S NAME REQUESTING AGENCY FACILITY NUMBER
; REQUEST CODE
MARGIE WHITAKER 045405532
4A
CODES
--
1. ORIGINAL A. FIRE CLEARANCE
LICENSING DEPARTMENT OF SOCIAL SERVICES
2. RENEWAL B. LIFE SAFETY
AGENCY COMMUNITY CARE IICENSING
NAME AND 520 COHASSET ROAD, SUITE 170
3. CAPACITY CHANGE
ADDRESS CHICO, CA 95926
4. OWNERSHIP CHANGE
5. ADDRESS CHANGE
FAX # (530) 895-5934
s. NAME CHANGE
7. OTHER
AMBULATORY NONAMBULATORY BEDRIDDEN TOTAL CAPACITY
CAPACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY CAPACITY PREVIOUS CAPACITY
2
4 0 24
F CILITY NAME �- ~ LICENSE CATEGORY
ITTLE FOLKS PRESCHOOL 850
...._ ........ _........ ........._......_...._................... I. .... .......... ................. ...... ...... _........... . _ ...... ._._ ............ ....... _ ........... .
S REET ADDRESS (ActualLocation) NUMBER OF BUILDINGS
855 BURNAP AVE.
_ ......_ ......... ..
Cl TY RESTRAINT
HICO NO
F CILITY CONTACT PERSON'S NAME — - HOURS
ATHLEEN CORBETT (530) 894-5437 M -F 7AM - 6PM
S ECTAL CONDITIONS
RANGE OF OWNERSHIP. REQUESTING FIRE CLEARANCE: FOR 24 AMBULATORY PRI SCI -1001, CI-1II,DREN (AGES 2 - K)
TO BE COMPLETED BY INSPECTING AUTHORITY
CLEARANCE +DENIAL CO
_ .
CODtS
FIRE BUTTE COUNTY FIRE DEPT. di
FIRE CLEARANCE GRANTED
AUTHORITY 176 NELSON AVE.
AME AND 2. FIRE CLEARANCE DENIED
DDRESS OROVILLE, CA 95965-3425 A. EXITS
ATTN B. CONSTRUCTION
r 01 L4J
IN PECTOR'S NAME (TypedorPrl �ld)
154
00 07p-- 5 � e
IN PECTION DATE INSPECTOR'S SIGNATURE(7+
2 3 �S
EX LAIN DENIAL OR LIST SPECIAL CONDITION
`"�- C. FIRE ALARM
D. SPRINKLERS
f ELEPHUNE NUMBER f CFIRS NUMBER € OCCUP/CY LASS
6 E. HOUSEKEEPING
F. SPECIAL HAZARD
Pr' ed G. OTHER
RECEIVED
SE? 2 8 2008
L•anmunllY Can Ua�ln9
Fire Prevention Bureau Butte County Fire Rescue White CoPY- Busine/
176 Nelson Avenue California Department of Forestry Yellow Copy — Occupancy File
Oroville, CA 95965 and Fire Protection Pink Copy — Station File
Telephone 530-538-7888Facility Inspection Report Occ. Class.
530-538-2105
Address: 7e<j— j � 1T�,. , P Business Name: � � f � S
Owner/Manager: 1C Bus: c 3 Hm: Fax.
Assistant Manager: Bus: Hm:
Building Owner:�v50�� Bus: •^ e , Hin:
Address:
AN iNCPFf TTInN nF V[IITR FAf'HXrV REVEALED TAE FOLLOWING:
1.
Fire Extinguishers: Required, service due _
10.
Exit(s) obstructed, inadequate
2.
Extension cords: Excess use, defective
11.
Exit sign(s) required, illumination
3.
Excessive rubbish, trash, debris
12.
Exit sign lights need replacing
4.
Fire alarm system defective
13.
Exit lighting: Required, defective C
5.
Sprinkler -system: Service required, defective
14.
Smoke detectors: Required, defective v 1
_6.
Kitchen hood extinguishing system service -due
15.
Wiring: Exposed, damaged connectors, etc.
7.
Fire walls, ceilings, fire doors, draft stops ; r '
16.
Heating system: Defective appliance, flue combustibles
8.
Knox Box keys �_-------
17.
Address posted and visible from road
9.
Fire Drill Witnessed Yes ❑ No ❑
18.
Other
DETAILED EXPLANATION AND CORREUHUAS: I:VKK>N:(:1ED:
W U L i I Z�L. Nfou 21- C G L ✓ �! r �� I -
r"
G, it, QS '-, i t rr- Z
t
— 1j.I (. -2 0Xfi J I#J 72-L4 1 JL2_1-7"; -'a e� NiCI'' 2IZOr- Fle"I/:.
ate: f G Discussed with: Signed: /
Y(Print) &-W tf 4 ,
Inspecfm icer:,,� 7
r —
Battalion 1 2 3 '4 5 6 7 Station: Lf FPB K�
ERE PREVENTION SAVES LIVES, PROPERTY, AND BUSINESS. YOUR COOPERATION WITH
ORRECTING THE ABOVE LISTED ITEMS IS APPRECIATED. RE -INSPECTION DATE:
Fire Prevention Bureau
Butte County Fire Rescue
White Copy - Business
176 Nelson Avenue
California Department of Forestry
Yellow Copy - Occupancy File
roville, CA 95965
and Fire Protection
Pink Copy - Station File
lephone 530-538-7888
Facility Inspection Report
Occ. Class. DCL F - 3—
Fax 530-538-2105
Fire alarm system defective
13.
Address: 2e5
Business Name: c.tTl 9w - �pLY$ ev !✓5CAA CO
Owner/Manager:
Bus: 43-M 37
Hm: -34S-3312 Fax:
Assistant Manager:
Bus:
Hm:
Wiring: Exposed, damaged connectors, etc.
Building Owner: T"Ff ke
.. Bus:
Hm: 3 tj . gr-9fia
Heating system: Defective appliance, flue combustibles
Address:
Knox Box keys
17.
AN nvcpFCT1nN nF VnTTR FACYLITV RFVFAi,F,D TAF. FOLLOWING:
1.
Fire Extinguishers: Required, service due
10.
Exit(s) obstructed, inadequate
2.
Extension cords: Excess use, defective
11.
Exit sign(s) required, illumination
3.
Excessive rubbish, trash, debris
12.
Exit sign lights need replacing
4.
Fire alarm system defective
13.
Exit lighting: Required, defective
5.
Sprinkler system: Service required, defective
14.
Smoke detectors: Required, defective
6.
Kitchen hood extinguishing system service due
15.
Wiring: Exposed, damaged connectors, etc.
7.
Fire walls, ceilings, fire doors, draft stops
16.
Heating system: Defective appliance, flue combustibles
Knox Box keys
17.
Address posted and visible from road
'77[8.
9.
Fire Drill Witnessed Yes ❑ No ❑
18.
Other
DETAILED EXPLANATION AND CORREC'FIONN: UVKKE(l1 L":
ate:
Discussed with:
Signed:
7hj 10
(Print) KATXe M0 VO4_�
�attalion
Inspecting Offic r:'
1 2 3 4%5 6 7
Station: r2 FPB
4
PIRE PREVENTION SAVES LIVES, PROPERTY, AND BUSINESS. (YO)UH COUPE1WHON W1,171
ORRECTING THE ABOVE LISTED ITEMS IS APPRECIATED. RE -INSPECTION DATE:
_-r
Fire Prevention Bureau
176 Nelson Avenue
Qroville, CA 95965
;lephone 530-538-7888
Fax 530-538-2105
A.�3utte County Fire Rescue '-'White Copy - Business
California Department of Forestry Yellow Copy - Occupancy File
and Fire Protection Pink Copy - Station File
Facility Inspection Report Occ. Class. )E_ :'
Address: Business Name: r
Owner/Manager: Bus: =,t Fax:
Assistant Manager: Bus: ' Hm:
Building Owner. ! Bus: Hm: 4,1 2 !�;
Address:
.,.r n►mnsrrrrniv nT WITT'D FA(n TrV RF.VF.AT.FM TAF FOLLOWING:
I.
Fire Extinguishers: Required, service due
10.
Exit(s) obstructed, inadequate
2.
Extension cords: Excess use, defective
11.
Exit sign(s) required, illumination
3.
Excessive rubbish, trash, debris
12.
Exit sign lights need replacing
4.
Fire alarm system defective
13.
Exit lighting: Required, defective
5.
Sprinkler system: Service required, defective
14.
Smoke detectors: Required, defective
6.
Kitchen hood extinguishing system service due
15. Wiring: Exposed, damaged connectors, etc.
7.
Fire walls, ceilings, fire doors, draft stops
16.
Heating system: Defective appliance, flue combustibles
8.
Knox Box keys
17.
Address posted and visible from road
9.
Fire Drill Witnessed Yes ❑ No ❑
18.
Other
DETAILED yE� XPLANATlUN AMU UUxtCLU 11VAn: v���- iLL•
tit?^Y�Pi l frT"ii1 iA�i is-'
Discussed with:
Signed:
Battalion 1 2 3' 4 5 6 7 I Station: FPB
FIRE PREVENTION SAVES LIVES, PROPERTY, AND BUSINESS. YOUR COOPERATIONW
CORRECTING THE ABOVE LISTED ITEMS IS APPRECIATED. RE -INSPECTION DATE:
t
Office of the State Fire Marsha{
Fire Safety Correction Notice
File No: ----_-__
Name: G fie`y L e, ,�!' CC 1°�ZJr�
Address:
SF
I I
CALIFORNIA STATE FIRE MARSHAL
The California Health and Safety Code and the State
deficiencies be corrected.
Fire Marshal's regulations require the following fire safety
1..i v IJ +l / �.G ✓ [_ r`-�
/ "C..e f f� J w
v i=,2
The above deficiencies are to be corrected within days. When ALL deficiencies have been corrected, sign
and return the certification on the opposite side of this form. If you have any questions, contact the Office of the State
Fire Marshal at ( )
ISSUED BY (Deputy State Fire Mar,hah RECEIVED BY DATE
J
EN -11 (Rev. 7/86) 89 88751 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field
Q
STATE OF CALIFORNIA
FIRE SAFETY INSPECTION REQ.. JEST
1.
3.
4.
6.
7.
8.
9.
850 (REV. 10-94) (REVERSE)
INSTRUCTIONS
This form is designed for use with a window envelope
Licensing or Requesting Agencies --Complete the following 19 sections -on this form
before submitting it to the fire authority having jurisdiction.
AGENCY CONTACT, 2. TELEPHONE 10. FACILI i Y NAME. Insert the name of the facility as it
NUMBER, 5. EVALUATOR. Enter the name and will appear on the license. List identifying sub name ifknown
telephone number of agency contact person. (i.e., Hacienda Corp/Medina Lodge).
PROGRAM. Licensing agency use. 11. LICENSE CATEGORY. Insert the category of license
REQUEST DATE. Enter date request was prepared.
being sought as it will appear on the license certificat
REQUESTING AGENCY FACILITY NUMBER. This
12. ADDRESS. Insert street address and city only. A post
is the file office box is not acceptable as only location.
e le number assigned by the licensing agency.
REQUEST in J3. NUMBER OF BUILDINGS. Insert the total number of
U ST CODE. Use the seven codes shown and se .
Q buildings to be used for housing of the occupants covered b
the appropriate number in the box following "Request Code". If g g p � y
the license.NAME CHANGE, please list previous -name. Insert date of
original request- is other-.-than--an- --original, - _ __ _14.._RES-CRARNT. Indicate if physical restraint (locked in a
AGENCY NAME AND ADDRESS. Enter the name and
room or the building) is to be used in the housing of the
address of the licensing facility requesting the inspection. occupants.
AMBULATORY--NONAMBULATORY--BEDRID-
DEN.
Capacity: Insert in the appropriate section, the capacity
of licensed ambulatory or nonambulatory oc-
cupants covered by this request.
15. FACILITY CONTACT PERSON --TELEPHONE
NUMBER..Indicate the name and telephone number of the
responsible individual at the facility to be contacted by the
fire authority.
16. HOURS. Indicate the number of hours the occupants are
housed at the facility (less than 24 or 24+).
Previous If request is for renewal or capacity changb. SPECIAL CONDITIONS. Indicate any
conditions
Capacity insert capacity of previous clearance.
unique to this request. As an example, if the inspection
q q p p
Total Show total licensed capacity. If the facility is request is for one building in a multi -building facility.
Capacity: intended to house part ambulatory, nonambu-
latory, and part bedridden, show the total of
the three types of occupants.
FIRE AUTHORITY CONDUCTING THE INSPECTION --COMPLETE THE FOLLOWING:
18. IRE AUTHORITY, NAME AND ADDRESS. Insert 22. OCCUPANCY CLASSIFICATION. Use California
e name and address of the fire authority where the facility is Building Code occupancy classifications and insert the
ocated. occupancy determined by the inspector.
19. LEARANCE/DENIAL CODE. Use the two codes: 1 23. INSPECTION DATE. Enter the actual date of the
or clearance granted, and 2 for clearance denied. If denied, inspection.
Iso include the appropriate letter code. As an example, De��. INSPECTOR'S SIGNATURE. To be signed b
the
ased upon exiting would be coded 2A.
inspector conducting the inspection.
20. NSPECTOR'S NAME.. Print the initial of the inspector's 25. EXPLAIN DENIAL OR SPECIAL
rst name and fu11 last name; insert the 'telephone number CONDITIONS. If clearance code ##2 is used briefly
here the inspector may be contacted. ' •
p y explain reason. This space is also to be used to specify any
21. FIRS I.D. NUMBER. Insert the fire department's num- additional limitations placed by the fire authority, such as the
er assigned by California Fire Incident Reporting System. use of certain floors or sleeping rooms approved for
nonambulatory clients.
•4
STA EOFCALIFC-'.41A
FI;E SAFETY INSPECTION REkjEST
-
See instructions on reverse.
STD 850(REV.10-94)
AGE 4CY CONTACTS NAME TELEPHONE NUMBER
I REQUEST DATE PROGRAM
D S/COMMUNITY CARE LICENSING 530 895-5033
1/12/00
EVALUATOR'S NAME REQUESTING AGENCY FACILITY NUMBER
REQUEST CODE
01 1/PAMALA SEXTON : 045402323
7A
CODES
- -----
1. ORIGINAL A. FIRE CLEARANCE
LI ENSING
GENCY DEPARTMENT OF SOCIAL SERVICES
2. RENEWAL B. LIFE SAFETY
N ME AND COMMUNITY CARE LICENSING
3. CAPACITY CHANGE
ADDRESS 520 COHASSET ROAD, SUITE 6
4. OWNERSHIP CHANGE
CHICO, CA 95926
5. ADDRESS CHANGE
6. NAME CHANGE
7. OTHER
AMBULATORY
NONAMBULATORY
BEDhDDEN
TOTAL CAPACITY
CAP CITY PREVIOUS CAPACITY
CAPACITY PREVIOUS CAPACITY
CAPACITY PREVIOUS CAPACITY
23 24
1 G
0
i
0 24
FACI ITY NAME
t
LICENSE CATEGORY
LIr 7LE FOLKS PRESCHOOL I n06/��-�
C�
850 CCC
STR ADDRESS (Actual Location)
NUMBER OF BUILDINGS
28 5 BURNAP
CITY
RESTRAINT
c CO
NONE
FACIL ITY CONTACT PERSON'S NAME
HOURS
TAMARA FERGUSON (530) 894-5437
DAYS
SPEC ALCONDITIONS
*FIRE CLEARANCE NEED
.:.,. .. -: ..... yr ....... s ':'. ... .. :. J.. .- :.. .:... :. ....,....<.. .: :.-.... ... ......,
...- r... -. -- .. -. ti. .. .. - . - .... .... : - . - ......... .. -ti
:
CO.IUIPLETEO. ��.. SPECTINC,�- AUTHORITY.
J
.`;.: :
,.:
CLEARANCE/DENIAL CODE
CODES
IRE STATE FIRE HAL 1. FIRE CLEARANCE GRANTED
AU1 HORITY 4 WILL URG LANE, SUITE A 1-7(o ^ I ✓,. I �� 2, FIRE CLEARANCE DENIED
NA E AND CHI , CA 95926 ' v`�
ADDRESS �' A. EXITS
B. CONSTRUCTION
C. FIRE ALARM
D. SPRINKLERS
INSPE TOR'SNAME(TypedorPrinted) TELEPHONE NUMBER CFIRS NUMBER OCCUPANCYCLASS
' E. HOUSEKEEPING
• ��F. SPECIAL HAZARD
� 00 � 3
INSPE TION DATE INSPECTOR'S SIG TU (T orPrinted)
G. OTHER
l 2�-
EXPLA N DENIAL OR LIST SPECIAL CONDITIONS
Z
Office of the State Fire Marshal
Fire Safety Correction Notice
File No: — _ -
Name: I 1 L L
Address: F) "
SF
� a
l I
CALIFORNIA STATE FIRE MARSHAL
The California Health and Safety Code and
deficiencies be corrected.
the State Fire Marshal's regulations require
the following fire safety
-
,7
V
The above deficiencies are to be corrected within days. When ALL deficiencies have been corrected, sign
and return the certificationonthe opposite side of this form. If you have any questions, contact the Office of the State
Fire Marshal at( )
ISSUED BY (Deputy State Fire Marshal) RECEIVED BY DATE
EN -11 (Rev. 7/86) 89 88751 DISTRIBUTION: GREEN—Facility WHITE—Region YELLOW—Field
ST CALIFORNIA
NONAMBULA-fORY
J BEDRIDDEN-
TOTAL CAPACITY
F RE SAFETY INSPECTION RE ST
�-�-
CAPACITY ,
PREVIOUS CAPACITY
---See
instructions -on
reverse.
ST . 850 (REV. 10-94)
- .
17
AG IyCY CONTACTS NAME
TELEPHONE NUMBER
FACILI rY NAME
REQUEST DATE
PROGRAM _
` S, C011 TUNIIY CARE -.-LENSING
530 895-50339/28/99
2. FIRE CLEARANCE DENIED
550- CCC
ST E pp DR
R AP-.$.',._
A. EXITS
EV LUATOR'S_ NAME..
_ -: ;- , -
"'REQUESTING AGENCY •FACILITY NUMBER r -
f.
REQUEST CODE
i) i /SEXTON0454
02323
"RESTRAINT
qlipo
lA
r� it�{
REQUESTEDRES
FACILIT e CONTACT -PERSON'S NAME
CF1RS NUMBER
CODES
"HOURS
TA14ARA FERGUSON 530 343--559
.- i - = --
E. HOUSEKEEPING -
F. SPECIAL HAZARD
1. ORIGINAL A. FIRE CLEARANCE
LI ENSING�`
SOCIAL SR ICES
G. OTHER
INSPECT16 DATE
2. RENEWAL B. LIFE SAFETY
. GENCY
N ME AND
CO C LICE.' SING
520. S 64..
3. CAPACITY CHANGE
a' DRESS
I ISDIM
OWNERSHIP CHANGE
_
CHICO CRS95926,
_'r,_ _ _
5. ADDRESS CHANGE
6. NAME CHANGE-
...7:OTHER`
....
AMBULATORY
NONAMBULA-fORY
J BEDRIDDEN-
TOTAL CAPACITY
CAPA ITY
PREVIOUS CAPACITY
CAPACITY ,
PREVIOUS CAPACITY
CAPACITY
PREVIOUS CAPACITY
17
CODES
FIE STATE - SIRE MARSHAL ~ : y'
FACILI rY NAME
AUTH. RITY _4 VILLIA'ISBURG LANE, STE
LICENSE CATEGORY
Ll TILE PEOPLE PRESCHOOL
DAYCARE
2. FIRE CLEARANCE DENIED
550- CCC
ST E pp DR
R AP-.$.',._
A. EXITS
;-J-99m, "W9 UI_1 31�IGS
.. -
2 5 5 . BURAP-
f.
CITY
-
"RESTRAINT
qlipo
D. SPRINKLERS
INSPECTO 'SEIAME )
(Typed or Printed ,
FACILIT e CONTACT -PERSON'S NAME
CF1RS NUMBER
y
"HOURS
TA14ARA FERGUSON 530 343--559
SPECIA CONDITION
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CLEARANCE /DENIAL CODE'
17
CODES
FIE STATE - SIRE MARSHAL ~ : y'
AUTH. RITY _4 VILLIA'ISBURG LANE, STE
1. FIRE CLEARANCE GRANTED
NAM AND . - CICO CA 95926 �� '•� �- - -
- t
-' ' • r`
2. FIRE CLEARANCE DENIED
ADD ESS
A. EXITS
r r
i
I
B. CONSTRUCTION
-
C. FIRE ALARM
D. SPRINKLERS
INSPECTO 'SEIAME )
(Typed or Printed ,
TELEPHONE NUMBER
CF1RS NUMBER
OCCUPANCY CLASS.
q
/ �- ��
E. HOUSEKEEPING -
F. SPECIAL HAZARD
G. OTHER
INSPECT16 DATE
INSPECTOR'SSIGNATU (T orPrirted)
EXPLAIN D NIAL OR UST SPECIAL CONDITIONS
iW.
L. .
STATE OF CALIFORNIA
FIRE SAFETY INSPECTION REQu-ST
SM 8,50 (REV. 10-94) (REVERSE)
INSTRUCTIONS
'his form is designed for use with a Window envelope
Licensing or Requesting Agencies --Comp et the following 19 sections -on this form
before submitting it to the fire authority.having Jurisdiction.
1. AGENCY CONTACT, 2. TELEPHONE NUMBER,
5. EVALUATOR. _r Enter the name and telephone
number of agency -contact person.
3. PROGRAM, Licensing agency use.
4. REQUEST DATE, Enter date request was prepared.
6. REQUESTING AGENCY FACILITY NUMBER. This is
the file number assigned 'by the licensing agency.
7. REQUEST CODE, Use the seven codes shown and
insert the appropriate number in the box following VvRe-
quest Code If NAME CHANGE, please list previous
name. Insert date of original request is other than an
*
original.
8. AGENCY NAME AND APDRESS. Enterthe name and
address of the licensing -facility requesting the inspection.
M
Capacity: Insert in the appropriate section, the capacity
of licensed ambulatory or nonambulatory oc-
cupants covered by this request.
Previous If request is for renewal or capacity change,
Capacity: insert capacity of previous clearance.
Total Show total licensed capacity. If the facility IS
Capacity: intendedtohouse part arnbulatory,--nonambu-
lat6r*y-,. and part bedridden, show the total bf
the three types of occupants.
10. FACILITY NAME. Insert the name of the facility as It
will appear on the license. - List identifying sub narnt-31 if
known (i.e., Hacienda Corp/Medina Lodge).
11, LICENSE CATEGORY, Insert the category of license
being sought as it will appe.aromthe license cerfific-ate.
12.ADDRESS. Insert street address and city only. A post
office box is not acceptable as only location.
13. NUMBER OF BUILDINGS. Insert the total number of
buildings to be used for housing of the occupants
covered by the license.
14. RESTRAINT. Indicate if physical restraint (locked in a
ro-om or the building) is to be used inthehousing of the
occupants.
15. FACILITY CONTACT PERsod 4ZLEPHONEWUMP
BER, Indicate the name and telephone _number of the
responsible individual at the facility to be contacted by
-the fire authority.
16.HOURS. Indicate the number of hours -the occupants
are housed at the facility (less than 24 or 24+).
17., SPECIAL CONDITIONS. Indicate any conditions
unique to this request. As an example, if the inspection
request is for one building in a mu'Iti-building facility,
FIRE AUTHORITY CONDUCTING THE INSPECTION—COMPLETE THE FOLLOWING:
18, FIRE AUTHORITY, NAME AND ADDRESS,, Insert the
name and address of the fire authority where the facility is
located
19. CLEARANCE/PENIAL COEM Use the two codes: I
for clearance granted, and 2 for clearance denied. If
denied, also include the appropriate letter code. As an
example, Denial based upon exiting would be coded 2A.
20. INSPECTOR'S NAME. Print the initial of the i1rispector's
L
first name and full last nafne;insert the telephone number
where the inspector may be contacted.
21. CFIRS I.D. NUMBER. Inisert the fire depart.ment"s num-
ber r -.0
ber assigned by California ire Incident Reporting System.
22. OCCUPANCY CLASSIFICAMON. Use California
Building Code occupancy classifications and insert the
occupancy determined by the 'inspector.
23. INSPECTION DATE. Enter the actual date of the
inspection.
24. INSPECTOR'S SIGNATURE. To be signed by the
inspector conducting the inspection.
25. EXPLAIN DENIAL OR SPECIAL CONDITIONS. If
clearance code #2 is used, briefly explain reason. This
space is also to be used to s ' pecify any additional
limitations placed by the fire authority, such as the use
of certain floors or sleeping rooms approved for
nonambulatory clients.
@0 OSP 98 14587
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