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Adult Family Hom (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> • e References:2012 IRC Section R325(WAC 51- <br /> 111 <br /> APPLICATION NUMBER: B l i d 8 - 06 4" <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: 5 22 2 V r`%UQ' 6.)CZN- WiN nl 3 2.©3 ASSESSOR'S TAX/PARCEL#943.i" 0 0_0Q i b o 5 <br /> SECTION 2-APPLICANT INFORMATION <br /> PROPERTY OWNER NAME: (ui b 5 C) 1�\� �ei l off'0 MQ' Ce DAYTIME PHONE: <br /> AFH LICENSEE NAME(IF DIFFERENT): DAYTIME PHONE: <br /> SECTION 3- FLOOR 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 /> 11 8 qs <br /> NOV 2 3 2021 <br /> CITY OF EVERET'I' <br /> Permit ServiCes <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: DATE: <br /> ['PROPERTY OWNER DAPPLICANT . D LICENSEE <br /> Effective:2013 July 01 <br /> Updated: 2013 May <br />