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Adult Family HoAFH) LOCAL BUILDING INSPENON CHECKLIST <br /> C References:2018 IRC Section R330(WAC=51- <br /> APPLICATION NUMBER: <br /> SECTIONS 1. 2. 3.AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br /> SECTION 1— PROPERTY INFORMATION <br /> SITE ADDRESS: 2C1 E Ivl+erCHj AVC, Everett, Wf\ c152.05 ASSESSOR'S TAX/PARCEL#:00480200g01(000 <br /> SECTION 2 —APPLICANT INFORMATION <br /> PROPERTY OWNER NAME: ALL PO(il7 COWIT LLC DAYTIME PHONE: (2.0(P) gz0-5320 <br /> AFH LICENSEE NAME(IF DIFFERENT): DAYTIME PHONE: (2-CM C12.0'532-0 <br /> SECTION 3— FLOOR PLAN <br /> On a separate sheet of paper (8 1/2 X 11) draw a Boor 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 /> SECTION 4— DISCLAIMER/SIGNATURE BLOCK <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 /> NAMEfifnLE: DATE: a/25I2022 <br /> 0 PROPERTY OWNER rx I APPLICANT Q LICENSEE <br /> implementation Date: 2021 February 01 <br /> 1r) Updated:2021 February <br />