1711 125TH PL SE 2024-11-15 - Laserfiche WebLink

Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST Code References: 2018 IRC Section R330 (WAC 51-51) APPLICATION NUMBER: SECTIONS 1. 2. 3. AND 4 MUST BE COMPLETED By APPLICANT BEFORE INSPECTION WILL BE PROCESSED SITE ADDRESS:y+I 1 N&�-TT v)A PROPERTY OWNER NAME: ff` Yt ` vFutkoj� AFH LICENSEE NAME (IF DIFFERENT): �_ew v 1 1 CA` 2 q V-12-0-3 ASSESSOR'S TAX/PARCEL#: DAYTIME PHONE: 42 �- DAYTIME PHONE: 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. 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 the9wner o he above premises to request inspection for the operation of an Adult Family Home at this location. I agree to hold harml ss the ju sdiction conducting such inspections, at my request, as to any claim (including costs, expenses, and attorneys, fees I rred,in the in stigation of such claim), which may be made by any person, including the undersigned, and filed against the jurisdi ion, lut o w lerp such claim arises out of the reliance of the jurisdiction, including its officers and employees, upon the accur cy f inf m tion supplied to the jurisdiction as a part of this application 411112024 NAME/TITLE: DATE: GPROPIIRTYbWN1 R () APPLICANT Q LICENSEE Implementation Date: 2021 February 01 Updated: 2021 February