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HomeMy WebLinkAboutBUSINESS PLANiT"". FIRE MARSHAL COPY DISTRIBUTION -1K.:: SAFETY INSPECTION REQUEST i-3•STATE FIRE MARSHAL -*. ~~"~-~"' SEE REVERSE OF COPIES 2 AND 5 FOR INSTRUCTIONS FOR COMPLETION >TD~850 (REV 8/86) 2-FIRE AUTHORITY 1. REQUEST DATE 2. PROGRAM 4.5-LICENSING AGENCY 02/18/2005 051975 3. AGENCY CONTACT 4. TELEPHONE N0. 5. EVALUATOR Cher 1 Fuller, AGPA (661) 336.0543 Helen Holt, HFES 6. SFM REGION 7. SFM I.D. N0. 8. REQUESTING AGENCY FACILITY N0. 9. REQUEST CODE SOUTHERN 0000198 5A CODES Department of Health Services 1. ORIGINAL A. FIRE CLEARANCE 10. AGENCY Licensing and Certification 2. RENEWAL B. LIFE SAFETY NAME Bakersfield District Office 3. CAPACITY CHANGE AND 1200 Discovery Plaza, Suite 120 4. OWNERSHIP CHANGE ADDRESS Bakersfield, CA 93309 5. ADDRESS CHANGE 6. OTHER 11. AMBULATORY NON AMBULATORY TOTAL CAP. DATE OF LAST FIRE CLEARANCE ;APACITY AGE RANGE (Y ARS) PREVIOUS CAPACITY AGE RANGE (Y RS) PREVIOUS TO 18 18 TO 65 AND CAPACITY TO 18 18 TO 65 AND CAPACITY 19. FACILITY 65 OVER 65 OVER CODE 0 0 0 0 0 0 0 0 0 0 0 13. 12. FACILITY NAME 13. N0. BLDGS CODES CALIFORNIA AVENUE COMMUNITY HEALTH CENTER 1 1. SNF 10. HHA 14. STREET ADDRESS (ACTUAL LOCATION) 15. RESTRAINT 2: GACH 11. ADHC D 601 CALIFORNIA AVE 4. SPHOSP 13. CLINI CS CITY ZIP CODE 16. HOURS 5. APH 14. REFRLAG 6. PHF 15. UNLICEN BAKERSFIELD, CA 93304 7. ICF 16. JAIL 17. FACILITY CONTACT PERSON TELEPHONE N0. 16A. SPECIAL 8• ICFDD 17. OTHER 9. ICFDDH STEPHEN SCHILLING (661) 323.6086 SPECIAL INSTRUCTIONS: Fire Clearance requested for change of location. © f ~ ~ ~/V L/~l.:r'~ L~fh./C-" 6~1~.~ TLS 1== l C' La ~'.•~ ~ ~ ~ ~~ TO BE COMPLETED BY ~ INSPECTING AUTHORITY 26. CLEARANCE CODE 18. FIRE AUTHORITY NAME AND CODES ADDRESS 1. FIRE CLEAR. GRANTED 2. FIRE CLEAR. DENIED 3. FIRE CLEAR. WITHHELD 27 . DENIAL CODE TO BE COMPLETED BY INSPECTING AUTHORITY CODES 21. INSPECTOR'S NAME TELEPHONE N0. 22. CFIRS. 23. T-19 OCC. ~~ ID N0. CLASS 1. EXITS ( ~ 1 ~ ~(Sj''(~ tb` 3 2. CONSTRUCTION ~iiL ~ . ~ IC `_~~ ~ _ a 3. FIRE ALARM 24. IN P. DATE 25. I TOR' SIGN ~ 4. SPRINKLERS ~~ E ~ d(a i~ 6. SPECIAL HAZARD 28. EX LAIN~DENIAL OR LIST SPECIAL CONDI IONS 20. REGION Department of Health Services/Life Safety Unit OFFICE 464 West 4th Street, Suite 529 AND San Bernardino, CA 93401 ADDRESS STATE FIRE MARSHAL USE ONLY ' CI~'Y FIRE DEI~'AI~TN'iEN°~', --_ INSPECTION RECORD ~~ this Card ~t ti~~ ~®b :Zits end ~~ N~'i' Remove ~r ~ar~ti~n ®f V01®rk UL -- 300 SYSTEM PRIOR TO OCCUPANCY OF ANY STRUCTURE, ALL FIRE PROTECTION SYSTEMS SHALL BE INSTALLED, COMPLETED, AND ACCEPTED BY THE CITY FIRE DEPARTMENT. AFIRE DEPARTMENT IFINALI ~r`i~3r~~ntr~ ~,lr'C.~.~ REMARKS: BUILDING ADDRESS 3C~ ` rv ~, C..~ JOB DESCRIPTION ~-ir-~p S ~-iKJlc ~e.~+ OCCUPANCY TYPE. ,~ OWNER CC,~;ti~ S~;C ~rA< 1Jr 6 T~4 PERMIT NO. - O 5 O CONTRACTOR ~(r,~{ :~'~ Inspecti~~i Reryuest Phvne Nc~. 326-3979