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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: ��� ��/ '�� SL ��l l.V- kk ASSESSOR'S TAX/PARCEL#:------- _ <br /> SECTION 2—APPLICANT INFORMATION <br /> PROPERTY OWNER NAME: ��e�L� v��`��� DAYTIME PHONE: 1 5 '56�) J�OoI <br /> AFH LICENSEE NAME(IF DIFFERUM: 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, 6, C D, E and F. <br /> Label all components for exiting i.e., stairs, ramps, platforms, lifts and <br /> elevators. � CJ) <br /> ILI NOV 2 2 2.023 ti <br /> CITY Off;" EVEIaETT <br /> Permit Services <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/TI'1'LE: <br /> PROPERTY OWNER QAPPLICANT 0 LICENSEE <br /> Implementation Date: 2021 February 01 <br /> Updated: 2021 February <br />