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Adult Family HomFH) LOCAL BUILDING INSPECJN CHECKLIST <br /> Code eferences:2018 IRC Section R330(WAC 51-5 <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 /> 902 110TH PL SE , EVEI .ETT, WA 98208-4010 007�2G�00000000 <br /> SITE ADDRESS: ASSESSOR'S TAX/PARCEL#: - <br /> SECTION 2—APPLICANT INFORMATION <br /> PROPERTY OWNER NAME: ANALEM WOLD & ASEFA ELEN DAYTIME PHONE: 20(099235GO <br /> AFH LICENSEE NAME(IF DIFFERENT): DAYTIME PHONE: <br /> SECTION 3— FLOOR PLAN <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 /> SECTION 4— DISCLAIMER/SIGNATURE BLOCK <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 daim 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 /> NAME/TITLE: DATE: <br /> [x PROPERTY OWNER CI APPLICANT El LICENSEE <br /> Implementation Date:2021 February 01 <br /> I k „ Updated: 2021 February <br />