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PE7?/0/7734—e1P63. . °l'e - <br /> ._.z ____ -_ e:_—__ a A i--e!% a e_e cx_ _._c a_. aee�.c- - __ __ _ _ <br /> f"fYMgL a ] iivFna. ;Aii ii Uwe%I wr=-a i_ "IMF loft iL.w::a'v •- ..r.. v..r...wow....• <br /> Code References:2012 IRC Section R325(WAG 51-51) <br /> APPLICATION NUMBER: <br /> SECTIONS 1.2.3.AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br /> Vii, <br /> >- _-_-7.'--2=F•2°'_'E't' - <br /> /LHS <br /> Se <br /> SITE ADDRESS: � � i ( ASSESSOR'S TAX/PARCELik I 2f) 0 f 3 0 0 0 <br /> SECTION 2—APPLICANT INFORMATION <br /> PROPERTY OWNER NAME ///-//Fl n /1\ 1,/// /i/-'/i1-/ DAYTIME PHONE: 't-'' t✓ J f �'.I I '7/ <br /> • _ c A tt n t <br /> AFH LICENSEE NAME(IF DIFFEREW): .1/L k'� / i J 7%t?fc i I•t DAYTIME PHONE: ,F.0.6 `P 7 7 t7/ <br /> _ SECTION 3—FLOOR-P.LAhI_ a ._.- <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 /> elevators. <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 /> F <br /> PROPERTY OWNER CIAPPLICANT 0 LICENSEE <br /> Updated:tad: 2013 1‘,, ,-.;, <br /> r <br />