HomeMy WebLinkAboutLicense Renewal Form 0703225 RESIDENTIAL ASSISTED LIVING FACILITY (RALF)
APPLICATION FOR FACILITY LICENSE IN IDAHO
ADDENDUM B—LOCAL APPROVALS
PLEASE TYPE OR PRINT
I. GENERAL INFORMATION
a.Assisted Living Facility Name(must match the name given on the Application Part A—limit 55 characters)
Pine Oaks Senior Living
b.Physical Street Address: c.City(must be in Idaho): d.Zip Code:
1367 Locust Street North Twin Falls �88301-3477
h.Facility Phone Number(include area code): i.Facility Fax Number(include area code):
(360) 254-9442 (360) 254-1770
j.E-mail Address for Licensing and Certification Contacts: k.Requested Bed Capacity:
licensing@sincerisl.com 80
II. FIRE/SAFETY INFORMATION
a.The facility is located in a local fire district,or the lawfully constituted fire authority will respond to a fire at the facility.
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Signature of Local Fire Authority Date ( J Z�
b.The facility's electrical wiring meets the applicable electrical codes for that structure(s)and is safe for occupancy.
Signature of Licensed Electrician Date
c.If the facility has a private water supply and/or sewage system,the Department must receive a statement from the local environmental health
agency stating that the water supply and/or sewage disposal system(s)meet the requirements of the Department.
ATTACH a copy of the last Health Department Laboratory Water Test,if the facility has a private water supply.
ATTACH documentation stating that the Health Department has checked the sewage system,if the facility has a private sewage system.
III. ZONING/BUILDING/FIRE CODES
a.The facility meets the applicable local zoning codes. No enforcement issues are pending)
Signature of Local Zoning Official Date
b.The facility meets the applicable local building codes.(No enforcement issues are pending)
Signature of Local Building Official Date
c.The facility meets the applicable local fire codes.(No enforcement issues are pending)
Division of Licensing & Certification Updated 1/13/2016
Signature of Local Fire Inspector Date
Division of Licensing &Certification Updated 1/13/2016