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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References:20121RC 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: 103/7 z% /,4 rv-epe /i(/ ASSESSOR'STAXIPARCEL#: - <br /> SECTION 2-APPLICANT INFORMATION <br /> PROPERTY OWNER NAME: I`'Gs y-e--. T2 l� S .4i DAYTIME PHONE: ast,6 -77 p 2/o7 <br /> AFH LICENSEE NAME(IF DIFFERENT): Pon y CeNtet,taA. DAYTIME PHONE: `T 2 3z 26 9-f <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 to the best of my knowledge, and that I <br /> am requesting or I am authorized by the owner of the above premises to request inspection for the operation of an Adult•Family <br /> ' Home at this location. I agree to hold harmless the jurisdiction conducting such inspections, at my request, as to any claim <br /> (including costs, expenses, and attorneys'fees incurred in the investigation of such claim), which may be made by any person, <br /> including the undersigned, and filed against the jurisdiction, but only where such claim arises out of the reliance of the <br /> jurisdiction, including its officers and employees, upon the accuracy of the information supplied to the jurisdiction as a part of <br /> this application., <br /> NAME[TITLE: -s -Q _ DATE: /©lig(WI-PROPERTY OWNER 1CJAPPLICANT ❑LICENSEE <br /> Effective:2013 July 01 <br /> Updated:2013 June ' <br />