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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST Code References: 2018 IRC Section R330 (WAC 51-51) �a t APPLICATION NUMBER: SECTIONS 'I. 2. 3. AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED SECTION 1— PROPERTY INFORMATION � II'IJ W- A SITE ADDRESS: 2) /�1l/�.Ae Zgaf�� ASSESSOR'S TAX/PARCEL#:------------ PROPERTY OWNER NAME: S, � DAYTIME PHONE , 1'L AFH LICENSEE NAME (IF DIFFERENT): SECTION 3 — FLOOR PLAN 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. SECTION 4 — DISCLAIMER/SIGNATURE BLOCK 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 the owner of the above premises to request inspection for the operation of an Adult Family Home at this location. I agree to hold harmless the jurisdiction conducting such inspections, at my request, as to any claim (including costs, expenses, and attorneys' fees incurred in the investigation of such claim), which may be made by any person, including the undersigned, and filed against the jurisdiction, but only where such claim arises out of the reliance of the jurisdiction, including its officers and employees, upon the accuracy of the Information supplied to the jurisdiction as a part of this application. NAME/TITLE: Ems- t� t 0 to 4-6-y/ DATE: PROPERTY OWNER 0 APPLICANT 0 LICENSEE Implementation Date: 2021 February 01 Updated: 2021 February