2505 PANAVIEW BLVD 2020-06-18 - Laserfiche WebLink

1.9 Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST CO-de ReferencegT 2015-IR-C Section R325(WAC 51=51) APPLICATION'NUMBER: - SECTIONS 1. 2. 3. AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED SECTION 1— PROPERTY INFORMATION ci 5.14)3 SITE ADDRESS: 2.3 o5Ati4 vi f6) vi LL-veoeht1-4211ASSESSOR'S TA>C/PARCEL#: SECTION 2—APPLICANT INFORMATION PROPERTY OWNER NAME: ci7 (L9 1M 0/1 k4ttiate--e DAYTIME PHONE: 20L; 1+22_ 320 AFH LICENSEE NAME(IF DIFFERENT): t k3 ei-i-110 hem 149L t-f DAYTIME PHONE: 2.06 g9 SECTION 3— FLOOR PLAN On a separate sheet of paper (8 1/2 x 11) draw a floor plan (including all floors) of your prospective AFH. Include all sleeping rooms (bedrooms) indicating which bedroom is: A, B, C D, E and F. Label all components for exiting i.e., stairs, ramps, platforms, lifts and elevators. SECTION 4— DISCLAIMER/SIGNATURE BLOCK 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 requesting or I am authorized by the owner of the above premises to request inspection for the operation of an Adult Family Home at this location. I agree to hold harmless the jurisdiction conducting such inspections, at my request, as to any claim (including costs, expenses, and attorneys' fees incurred in the investigation of such claim), which may be made by any person,including the undersigned, and_filed ag ainstthe_jurisdiction,-but-only_wher_e_such_claint_arises_ollt_of_the_reliance_of_the_jurisdiction,_including_its_officers_and____ employees, upon the accuracy of the information supplied to the jurisdiction as a part of this application. NAME/TITLE: in Ma- >1 04 fy DATE: g /3e7 1/ 9, PROPER1Y OWNER D APPLICANT 0 LICENSEE (Effective July 1, 2013.) Effective:2013 July 01 Updated:2017 February