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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References:2012 IRC Section R325(WAC 51-51) <br /> APPLICATION NUMBER: <br /> SECTIONS 1.2.3.AND 4 MUST BE COMPLETED By APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br /> SECTIO PROPERTY" • ' ' • <br /> SITE ADDRESS: v 2 711n Aj?- S E fye_re4t ASSESSOR'S TAX/PARCEL#:_______-____ <br /> SECTION APPLICANT INFORMATION <br /> PROPERTY OWNER NAME:bat/"'-- L0(^f eye-1 Atro Add►5 J i rU DAYTIME PHONE: c�06 <br /> AFH LICENSEE NAME(IF DIFFERENT): v(-6Q(i V 1:P—LJ (1:We DAYTIME PHONE: <br /> SECTION •• ' PLAN <br /> On a separate sheet of paper (81/2 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 <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 /> NAME:/TITLE: DATE: 22 Feb 2033 <br /> OPROPERTY OWNER APPLICANT Cl LICENSEE <br /> EDVl"I W <br /> 0D <br /> FEB 2 3 2023 Effective:2013 July 01 <br /> Updated:2013 May <br /> CITY OF EVERETT <br /> Permit Service <br />