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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 /> SECTION • ' • + • <br /> 225 97TH PL. SE. EVERETT WA 98208 <br /> SITE ADDRESS, ASSESSOR'S TAWPARCEL#______ <br /> SECTION • • <br /> PROPERTY OWNER NAME: SAMPHORS KHLOCK & CHANRATANA KONG DAYTIME PHONE: 425-800-9156 <br /> AFH LICENSEE NAME(IF DIFFERENT): 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 i TV <br /> 'r ramps, platforms, lifts and <br /> elevators. <br /> MAY 10 2023 R <br /> ECEOVE <br /> CITY OF EVERETT FEB 2 7 2023 <br /> Permit Services <br /> CITY OF EVERETT <br /> Permit Services <br /> SECTION + 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 <br /> am requesting or I am authorized by the owner of the above premises to request inspection for the operation of an Adult Family <br /> Home at this location. I agree to hold harmless the jurisdiction conducting such inspections, at my request, as to any claim <br /> (including costs, expenses, and attorneys' fees incurred in the investigation of such claim), which may be made by any person, <br /> including the undersigned, and filed against the jurisdiction, but only where such claim arises out of the reliance of the <br /> jurisdiction, including its officers and employees, upon the accuracy of the information supplied to the jurisdiction as a part of <br /> this application. <br /> NAMErrITLE: CHANRATANA KONG DATE: 9/16/2020 <br /> R( PROPERTY OWNER ❑APPLICANT Q LICENSEE <br /> Implementation Date: 2021 February 01 <br /> Updated: 2021 February <br />