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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References:2=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 1 — PROPERTY INFORMATION <br /> SrrEADDRESS: V"PL O?2k?� AssessowsTAX1PARCEL#:----___-____ <br /> •N 2 -APPLICANT INFORMATION <br /> PROPERTY OWNER NAME: P htl e-C: `��Id j �A� DAYTIME PHONE: <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 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 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 tite 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 accuracy of the Information supplied to the jurisdiction as a part of this application. <br /> NAMFITITLE: P ,0( j) e , C-0 -f�.D C lag <br /> W�I G DATE: <br /> OROPERTY OWNER DAPPLICANT ©LICENSEE <br /> Implementation Date: 2021 February 01 <br /> Updated: 2021 February <br />