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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br />Code References: 2015 IRC Section R325 MAC 51.51) <br />APPLICATION NUMBER: <br />SECTIONS 1. 2. 3. AND 4 MUSTBE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br />SITE ADDRESS `�C) �1 S t EVfl.re � ` ' <br />—# —# -- ASSESSORS TAkPARCELsi <br />PROPERTY OWNEItNAME:_GC— `yO�-\ <br />DAYTIME PHONE: <br />AFH IJCENSEE NAME (tFDusfAEw)- _____ DAYTIME PHONE: <br />SECTION••• 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•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 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 anti <br />employees, upon the accuracy of the information supplied to the jurisdiction as a part of this application. <br />NAMEfTITLE: <br />QPROPERTY OWNER QAPPLICANT Q LICENSEE <br />DATE:-- --- ---- <br />(Effective July 1, 2013.) <br />Effective: 20131u1y 01 VIA,' <br />Updated: 2017 February <br />