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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST Code References:2018 IRC Section 8330(WAC 51-51) APPLICATION NUMBER: SECTIONS 1. 2.3.AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED SECTIONPROPERTY" • ' • SITE ADDRESS: wA ASSESSOR'S TAXJPARCEL#:_______ SECTION PROPERTY OWNER NAME: " r DAYTIME PHONE AFH LICENSEE NAME(IF DIFFERENT): ramL� , DAYTIME PHONE: • • • ' PLAN On a separate sheet of paper (8 112x 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. 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'fee ' n' in the Investigation of such claim),which may be made by any person, including the undersigned, and filed against the juris ' ion, only where such claim arises out of the reliance of the jurisdiction, including its officers and employees, upon the ac rac a infor supplied to the jurisdiction as a part of this application, p NAMFITITLE; DATE: �U P OP TX O R APPLICANT Q LICENSEE Implementation Date: 2021 February 01 Updated; 2021 February