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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References:2012 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 /> 1504 108th St SW 00442800000400 <br /> SITE ADDRESS: ASSESSOR'S TAX/PARCEL#: - <br /> SECTION 2—APPLICANT INFORMATION <br /> PROPERTY OWNER NAME: Eyerusalem Maird DAYTIME PHONE: <br /> AFH LICENSEE NAME(IF DIFFERENT): DAYTIME PHONE: <br /> SECTION 3—FLOOR PLAN <br /> On a separate sheet of paper (81/2 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 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 <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 /> NAME/TITLE: Eyerusalem Maird DATE: 10/27/2021 <br /> °PROPERTY OWNER DAPPLICANT D LICENSEE <br /> Effective: 2013 July 01 <br /> \ Updated:2013 June <br />