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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References:2018 IRC Section R330(WAC 51-51) 'I Q <br /> APPLICATION NUMBER: 13ZA1 )S"0 <br /> SECTIONS 1.2. 3. AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br /> -SECTIONPROPERTY • ' • <br /> SITE ADDRESS: 5 e5n SOW Zs/ E A-07. ASSESSOR'S TAX/PARCEL#_Z7DA436003I0000 <br /> SECTIONAPPLICANT INFORMATION <br /> PROPERTY OWNER NAME: DAYTIME PHONE: VO" <br /> AFH LICENSEE NAME(IF DIFFEREW): DAYTIME PHONE: <br /> SECTION • • ' PLAN <br /> On a separate sheet of paper (8 1/2 x 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 /> 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 A-hejurisdiction 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 juJ hti n, but only where such claim arises out of the reliance of the jurisdiction, including its officers and <br /> employees, upon the/6ccurack of the iafarmation supplied to the jurisdiction as a part of this application. <br /> NAME/TITLE: DATE: d v <br /> F.RTY OWN R DAPPLICANT Q IdCENSEF, <br /> Implementation Date:2021 February 01 <br /> Updated:2021 February <br />