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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br />Code References: 2015 IRC Section R325 (WAC 51-51) <br />• � Q� `,JkIckflQ _C(/� APPLICATION NUMBER. — 0�L <br />� <br />SECTIONS 1. 2. 3. AND 4 MUST BE COMPLETED By APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br />SECTION 1— PROPERTY INFORMATION <br />SITEADDRESS:1 0 101)4-1vx S+-Syj Eve ye -,=L 6122*SESSOR'STAX/PARCEL#:_______-____ <br />SECTION 2 — APPLICANT INFORMATION <br />PROPERTY OWNER NAME: B P_ Le_+t? )AS r-Yn— <br />AFH LICENSEE NAME (IF DIFFERErrr): E 1—'D 4 F 14 I.L r-- <br />SECTION 3 — FLOOR PLAN <br />DAYTIME PHONE: L O �— 5'ZI ` 533 <br />DAYTIME PHONE: 2 O(1,-- 5 A7--Q 3 0 9 <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 />I certify under penalty of perjury that the information furnished by me is true and correctto 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, includin its officers and <br />employees, upon the accuracy of the information supplied to the jurisdiction as a part of this application. <br />NAME/TITLE; 1 �C � �� ]"� 14 DATE: I <br />QPROPERTY OWNER <br />(Effective July 1, 2013.) <br />JDAPPLICANT 0 LICENSEE <br />Cs� <br />Effective: 2013 July 01 <br />Updated: 2017 February <br />