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gi10.3 - 017 <br /> Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References:2015 IRC Section R325(WAC 51-51) <br /> APPLICATION NUMBER: <br /> SECTIONS 1. 2. 3. AND4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br /> SECTION 1- PROPERTY INFORMATION <br /> SITE ADDRESS: (7ESC) I - ` 1 ( O4+ 'J ) C 4• ASSESSOR'S TAX/PARCEL#: - <br /> SECTION 2-APPLICANT INFORMATION <br /> 0Rv( I Zz_1 140 <br /> PROPERTYOWNERNAME. �G�► (� '�.t � DAYTIMEPHONE�CJ � <br /> AFH LICENSEE NAME(IFDIFFEREM): i an i�` —' ,_n r�� DAYTIME PHONE: 14-2. '� $� <br /> SECTION 3-FLOOR PLAN <br /> On a separate sheet of paper(8 1/2 x 11) draw a floor plan (including all <br /> floors) of your prospective AFH. Include all sleeping rooms(bedrooms) <br /> indicating which bedroom is: A, B, C D, E and F. <br /> Label all components for exiting i.e.,stairs, ramps,platforms, lifts and <br /> elevators. <br /> SECTION 4- DISCLAIMER/SIGNATURE BLOCK <br /> I certify under penalty of perjury that the information furnished by me is true and correct ti the best of my knowledge,and that I am <br /> requesting or I am authorized by the owner of the above premises to request inspection for the operation of an Adult Family Home <br /> at this location. I agree to hold harmless the jurisdiction conducting such inspections, at my request, as to any claim (including costs, <br /> expenses, and attorneys'fees incurred in the investigation of such claim), which may be made by any person,including the undersigned <br /> and filed against the jurisdiction, but only where such claim arises out of the reliance of the jurisdiction, including its officers and <br /> employees, upon accuracy of the info -,r,.. supplied, to the jurisdiction as a part of this application. <br /> NAMEITITLE:_3 (/�Y K' G< DATE: 12 Z-0 <br /> CIPROPERTY OWNER iSIAPPLICANT 0 LICENSEE <br /> (Effective July 1,2013.) <br /> Effective:2013 July 01 <br /> Updated:2017 February <br />