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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References:2018 IRC Section R330(WAC 51-51) i I <br /> APPLICATION NUMBER: <br /> CSECTIONS 1.2.3.AND 4 MUST aE COMPLETED By APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br /> SiSECTION 1-PROPERTY INFORMATION <br /> I E ADDRESS 5 to/ `vi 0A-1 !J i^ E V V ASSESSOR'S TAX-PARCELt <br /> SECTION APPLICANT • . • <br /> PROPERTY OWNER NAl-i E:-A�LJ &- �� DAYTIME PHONE: '3 -f - os <br /> AFH UCENSEE NAME(IF DIFFE0.ENJ)'— . _ DAYTIME PHONE:206 - 3.S4-q-0 r <br /> SECTION 3-FLOOR PLAN <br /> On a separate sheet of paper (8 1/7. 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 /> JUN 3 0 2022 <br /> CITY OF EVERETT <br /> permit Services <br /> SECTION 4-DISCLAIMER/SIGNATURE BLOCK <br /> I certify under penalty of perjury that the information furnshed by me is true and correct to the best of my knowledge, and that I am <br /> requesting or I am authoriLed 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 agairst the jurisdiction, but only where such claim arises out of the reliance of the jurisdiction, including its officers and <br /> employees, upon the accuracy of the information supplied to the jufLsdiction as a part of this application. / <br /> N.AM TITLE - ` 1,V / _ DATE. <br /> ¢JPROPER1% OWNER DAPPLIC V,I �]L.ICF:\tiFa: <br /> Implementation Date:2021 February 01 <br /> Updated:2021 February <br />