Laserfiche WebLink
AMOV060 <br /> Per fj26N " t / -SNSipE <br /> .r— <br /> Adult Family Home(AFH) LOCAL BUILDING INSPECTION CHECKLIST ,. <br /> Code Referertcest 2S11I}TRC Section R330(WAC 51.5I) <br /> APPLICATION NUMBER: <br /> SECTIONS 1,2,3,AND 4 MUST BE COMPLETED BY APPLICANT BEFORE(NtIpECTiON WILL BE PROCESSED <br /> • —PROPERTY •' • <br /> S11FADDRESS:_i* 0, � �Y`u) �J� 4�• �V+ y tih 0 <br /> nssessorrs Tnxmnrtcetn:_______•____ <br /> SECTIONP' • • <br /> PROPERTY OWNER NAME: Everett AFH LLC DAYTIME PHONE: 426-446-2073 <br /> i <br /> AFH LICENSEE NAME pF DIM PEND: DAYTIME PHONE: <br /> SECTIONFLOOR <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 /> SECTIONBLOCK <br /> I certify under penalty of pedury that the information furn(shed 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 Jurisdlcdon,but only where such claim arises out of the reliance of the Jurisdiction, Including Its officers a�j <br /> employees, upon the accuracy off the Information supplied to the Jurisdiction as a part of this application, <br /> NAMPITITLE; �i�/��/ y" UA'fd: 2-7-23 <br /> 13PROPFIITYOIVNER IJAPPLICANT 13LICBNSEE <br /> I <br /> i <br /> Implementation Date:2021 February 01 <br /> i <br /> JUL 10 2023 updated:2021 February <br /> CITY OF EVERETT <br /> Permit Services <br />