1714 127TH PL SE 2023-12-11 - Laserfiche WebLink

Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST Code References: 2018 IRC section R330 (WAC 51-51) /) C� APPLICATION NUMBER: �v u l SECTIONS 1. 2. 3. AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED SECTIONPROPERTY"•' • SITE ADDRESS: 1714 127TH PL SE, EVERETT, WA 98208-6516 28053000404800 ASSESSOR'S TAX/PARCELM SECTION APPLICANT , • • GEBEYEHU MEKONNEN/MELEKET AYNADIS 2064844197 PROPERTY OWNER NAME: _ _ DAYTIME PHONE: _ AFH LICENSEE NAME (IF oirreaeur): 17�2a( Z,( _ DAYTIME PHONE: SECTION 3 - FLOOR PLAN On a separate sheet of paper (8 1/2 x 11) draw a floor plan (including all floors) of your prospective AFH. Include all sleeping rooms (bedrooms) indicating which bedroom is: A, B, C D, E and F. Label all components for exiting i.e., stairs, ramps, platforms, lifts and elevators. nn jjjj MAY 1 1 2023 CITY OF E Y ER iJTT Permit Services SECTIONBLOCK 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 requesting or I am authorized by the owner of the above premises to request inspection for the operation of an Adult Family Home at this location. I agree to hold harmless the jurisdiction conducting such inspections, at my request, as to any claim (Including costs, expenses, and attorneys' fees incurred in the investigation of such claim), which may be made by any person, including the undersigned, and filed against the jurisdiction, but only where such claim arises out of the reliance of the jurisdiction, including its officers and employees, upon the accuracy off the�informmaatiiool supplied to the jurisdiction as a part of this application. NAMEfrrrLl:: DATE. ❑m OPIiR'I'V OWNLR 0,\PPLICAN'I' ❑ LICENSEE; EVE IF F'E8 1 CITY OF EVERETt Permit Services Implementation,Date: 2021 February 01 Updated: 2021 February