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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: <br /> SECTIONS 1. 2. 3. AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br /> SECTIONPROPERTY INFORMATION <br /> SITE ADDRESS: O;�t� ��� � �..i (� i/[ , /Y'yf �40,�-ASSESSOR'STAXIPARCEL#:------------ <br /> SECTIONAPPLICANT • ' i • <br /> PROPERTY OWNER NAME: DAYTIME PHONE: I�' <br /> AFH LICENSEE NAME(IF DIFFERENT: DAYTIME PHONE: <br /> SECTION ! • ' PLAN <br /> On a separate sheet of paper (8 1/2x 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 /> SECTION1BLOCK <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 /> NAM MITLE: 4 41 <br /> .�,..,(( — DATE: <br /> I�.IPROPERTYOWNER '{JAPPLICANT QLICFNSFF <br /> Implementation Date: 2021 February 01 <br /> Updated: 2021 February <br />