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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: 4 ,/ 0 <br />SECTIONS 1, 2, 3, AND 4 MUST BE COMPLETED By APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br />SECTION 1— PROPERTY INFORMATION <br />SITEADDRESS: 1202 CASINO RD. EVERETT, WA 98203 ASSESSOR'S TAX/PARCEL#:0394100201500 <br />SECTION 2 — APPLICANT INFORMATION <br />PROPERTY OWNER NAME: ZEWDU FASHIE <br />AFH LICENSEE NAME (IF DIFFERENT): <br />SECTION 3 — FLOOR PLAN <br />DAYTIME PHONE: 06-453-8023 <br />DAYTIME PHONE: <br />On a separate sheet of paper (8 1/2x 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 />SECTION 4 — DISCLAIMER/SIGNATURE 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 />NAME/TITLE: ZEWDU DATE: 6/13/2023 <br />®PROPERTY OWNER DAPPLICANT ❑ LICENSEE <br />Implementation Date: 2021 February 01 <br />Updated: 2021 February <br />