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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. AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br /> -SECTION 1-PROPERTY INFORMATION <br /> SITE ADDRESS_180/, 7e7-11 /-1 5e �Ct L L'4! !B 03 _ASSESSOR'S TAXIPARCEL# 7�� I 000o0/06 <br /> SECTION 2 —APPLICANT INFORMATION <br /> PROPERTYOWNERNAME: - &Li k t Avil4(/ _ l/�t/'e/� DAYTIME PHONE: 1125"-- 37 7362 <br /> AFH LICENSEE NAME(IF DIFFERBIT): V4It 1/1A(✓ -51/41 f t/l DAYTIME PHONE:20 57g eu 3 7 <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: 8, C D,E and F. <br /> Label all components for exiting Le.,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 to 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 harm 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 the accuracy of the infor n suppled to the jurisdiction as a part of this application. <br /> NAM ErrITLE: /01-'4 rei —1 vI✓ (C�f/ DATE:5f/4'8 <br /> ' PROPER1Y OWNER DAPPLICANT D LICENSEE <br /> (Effective July 1,2013.) �d <br /> .. Effective.20131u1y 01 <br /> Updated:2017 February <br />