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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References: 2018 IRC Section R330(WAC 51-51) <br /> APPLICATION NUMBER: ��� V 4A <br /> SECTIONS 1, 2, 3, AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br /> SECTIONPROPERTY" • ' • <br /> SITE ADDRESS:—G qn- l�q c� 'LfW L WYQN wPr I3Z0'1SSESS0R'STAXIPARCEL#:_______-____ <br /> SECTIONAPPLICANT+ • + • <br /> PROPERTY OWNER NAME:_ 'Pau R0 VQQ1)\tPJ DAYTIME PHONE: 2�6 <br /> 1 Z3 5SS <br /> AFH LICENSEE NAME(JF DIFFERENT): - �\(1L V` t24 44 U C DAYTIME PHONE: <br /> SECTION • • • PLAN <br /> On a separate sheet of paper (8 '/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 <br /> Label all components for exiting i.e., stairs, ramps, platforms, lifts and <br /> elevators. <br /> SECTIONBLOCK <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 claim 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(FITLE:_?aU k,%oe l n %(U2 <br /> DATE:- 312,s -q <br /> --- - - - <br /> -- <br /> MPROPERTY OWNER ❑APPLICANT Q LICENSEE <br /> D <br /> .��ov <br /> MAR 2 5 202+ Implementation Date: 2021 February 01 <br /> CITY 0 SeEReST <br /> Updated: 2021 February <br /> �Perm <br />