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Adult Family Horne (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References:Z.M 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 /> SITE ADDRESS: �-'fJ -�D�P �`L 'Y t V�1 4' Ly"� ASSESSOR'S TAX/PARCEL#;_______-____ <br /> LPROPERTY OWNER NAME: I/C DAYTIME PHONE: 20b 319 7 CO�3 <br /> owe- <br /> AFH LICENSEE NAME(IFDIFEREW): �� e o Adual Fti m i'/i DAYTIME PHONE: Zo6 -31 + D <br /> On a separate sheet of paper (8 1/2 x .1) draw a floor plan (including all <br /> floors) of your prospective AM 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 /> M116JR1011 • ' ' i • <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 /> re "esting 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 flied against the jurisdiction, but only where such claim arises out of the reliance of the jurisdiction, Including its officers and <br /> employees, upon the <br /> y�accuracy of the Information supplied to the jurisdiction as a part of this application. <br /> ` <br /> NAMEITITLE: �?c l�( l :l w P/1�L 4 DATE: (� �(7' _ Za <br /> #PROPERTY OWNER APPLICANT ®IACENSEE <br /> I <br /> i <br /> Implementation Date: 2021 February 01 <br /> Updated: 2021 February <br /> i <br />