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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br />Code References: 2018 IRC Section R330 (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 />SITEADDRESS:_7 rJa l( 7 Jf 1 UL�i�ETI W ASSESSOR'S TAX/PARCELM _______-____ <br />SECTION 2 - APPLICANT INFORMATION <br />PROPERTY OWNER NAME: l- PFv— DAYTIME PHONE: U6332- 62-S-?1 <br />AFH LICENSEE NAME (If DIFFERENT):%_S_r AmVOCAIE k1 LLC 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 />Ic ertifyunderpenaltyofperjurythi <br />izedbytheownerofthea bovepren <br />harmiessthejurisdictionconducti <br />estigationofsuchclaim),whichma) <br />claimarisesoutoftherelianceof the <br />a rtofth isa ppl ication. <br />NAMEITITLE: A, <br />nformationfurnishedbymeistrueandcorrecttothebestofmyknowledge,andthatIamrequestingorI amauthor <br />:orequestinspectionfortheoperationofanAdultFamiiyHomeatthislocation.lag reetohold <br />chi nspections,atmyrequest,astoanyclaim(includingcosts,expenses,andattorneys'feesincurredintheinv <br />i, I ncludi ngtheundersigned,andfil edagainstthejuris diction, butonlywh eresuch <br />tsofficersandemployees,upontheaccuracyoftheinformationsuppliedtothejurisdictionasap <br />V <br />PROPERTY OWNER DAPPLICANT D LICENSEE <br />(Effective Feb. 1, 2021 <br />DATE: <br />Implementation Date: 2021 February 01 <br />Updated: 2021 February <br />