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Adult Family Home (Affl) LOCAL, BUILDING YNSPECTION CHECKLIST <br />Code References: 2018 IRC Section R330 (WAC 51-51) <br />APPLICATION t` ummR: <br />SECTIONS 1. 2, 3. AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br />4'k ;' � SECTION - I�ROPERTY INFORMATION <br />i 4 1 Y <br />SITE ADDRESS: kSSESSOR'S TAXIPARCEL#� <br />��� (� F :�;�i��.'�.�r�nl�� �-,r�f��������Q!■ 2 ��C�- �l` Q y .,P�.G:-ter <br />PROPERTY OWNER NAME: /GE��5�"S/QL�/�_ DAYTIME PHONE: <br />AFH LICENSEE NAME (IF DIFFERENT): <br />DAYTIME PHONE: <br />c� i <br />• • ti A ' � A �w E�� �`�� �,�,, <br />� 7+ t <br />On a separate sheet of paper (8 1/2- x 11) draw a floor plan (including all <br />floors) ®f your prospective AFH. XncWde all sleeping roor is (bedrowns) <br />indicating which bedroom is# A, 131 C D, E and F. <br />Label all components for exiting i.e., stairs, ramps, platforms, lifts and <br />elevators. <br />SECTION 4-7DISCLAIMER/SIGNATURE BLOCK r { <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 <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, including its officers and <br />employees, upon the accuracy of the information supplied to the jurisdiction as a part of this application. <br />NANIEfrlTIT': y e-Ssi ��.( -- -- ' DATE: /CJ�G�%Z-3 <br />InPROPERTY OWNER 13AI'1'I,ICANT C"LICENSFE <br />Implementation Date: 2021 February 01 <br />Updated: 2021 February <br />