Laserfiche WebLink
Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References:2018 ERC 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 /> S€TE ADDRESS: ASSESSOR'S TAXIPARCELp:_ <br /> • 2 APPLICANT • . 1 • <br /> PROPERTY OWNER NAME: \AjV,.Va4.-,-B 16 Ll`--r i✓ R L=�28 -,1mt=G-1N�) &W6-- DAYTIME PHONE: d f)�=;LL!_ 3 <br /> AFH LICENSEE NAME(iFoIFFERENT): L l3 A E N 1 LG DAYTIME PHONEIn� `�J � I:—C �6 3 <br /> SECTION • • • PLAN <br /> On a separate sheet of paper (8 1/2x 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 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 off€ rs and <br /> employees, upon the accuracy of the Information supplied to the jurisdiction as a part of this application. <br /> NAME/TITLE:tA i P,Z-A -6(=1 a T� 1, f')tea P4 GC:tQ Bl�ry r/A- DATE: <br /> PROPERTY OWNER ©APPLICANT ❑LICENSEE <br /> (Effective Feb. 1, 2021 <br /> Implementation Date: 2021 February 01 <br /> Updated: 2021 February <br />