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4 <br /> Adult Family Home (AFH) LOCAL BUILDING INSPrION CHECKLIST <br /> Code References: 2009 IRC 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: 8720 9TH AVENUE SE, EVERETT, WA 98208 ASSESSOR'S TAX/PARCEL#:0040250000 - 1700 <br /> SECTION 2 -APPLICANT INFORMATION <br /> PROPERTY OWNER NAME: DAGNACHEW KASAHUN &TSION TAMRAT DAYTIME PHONE: 206-981-1629 <br /> AFH LICENSEE NAME(IF DIFFERENT): TANA AFH LLC DAYTIME PHONE: 206-981-1629 <br /> SECTION 3 — FLOOR PLAN <br /> APPLICANT MUST DRAW COMPLETE FLOOR PLAN/s ON THIS FORM(ALL FLOORS). PLEASE INCLUDE ALL SLEEPING ROOMS(BEDROOMS). <br /> ON THIS DRAWING, INDICATE WHICH BEDROOM IS A, B, C, D, E, AND F. LABEL ALL COMPONENTS FOR EXITING i.e.: STAIRS, <br /> RAMPS, PLATFORM LIFTS& 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 am requesting or I <br /> 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 <br /> harmless the jurisdiction conducting such inspections, at my request, as to any claim (including costs, expenses, and attorneys'fees incurred in the <br /> investigation of such claim),which may be made by any person, including the undersigned, and filed against the jurisdiction, but only where such <br /> claim arises out of the reliance of the jurisdiction, including its officers and employees, upon the accuracy of the information supplied to the <br /> jurisdiction as a part of this application. <br /> NAME/TITLE: TSION TAMRAT DATE: 6-15-2021 <br /> 0 PROPERTY OWNER ❑ APPLICANT 0 LICENSEE <br /> 08/01/10 <br />