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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br />Code References: 2018 IRC Section R330 (WAC 51-51) �jj} r' <br />APPLICATION NUMBER: K/" `' v <br />SECTIONS 1, 2, 3, AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br />SITE ADDRESS: 4015 FRIDAY AVE EVERETT, WA 98201 ASSESSOR-STAwPARCEL#:00468000100700 <br />PROPERTY OWNER NAME: TIGIST ERZ-R' &-Cil=@Rl---MARiAM-ALEMSHOWA DAYTIME PHONE: 206-288-9503 <br />7-MCFA (IFBOPPAI I Aryl <br />AFH LICENSEE NAME (IF DIFFERENT): LCAI-J �' A—FHLGL DAYTIME PHONE: <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 />J A N 0 4 2023 <br />CITY OF EVERET "' <br />Permit Services <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: TIGIST ZERERA <br />®PROPERTY OWNER QAPPLICANT ❑ LICENSEE <br />DATE: 12-06-2023 <br />Implementation Date: 2021 February 01 <br />Updated: 2021 February <br />