215 110TH PL SE 2025-06-30 - Laserfiche WebLink

Category 2: Sensitive Information Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST Code References: Z= IRC Section R330 (WAC 51-51) APPLICATION NUMBER: B241 2-034 SECTIONS 1. 2.3. AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED io SITE ADDRESS: 215 110TH P L SE ASSESSOR'S TAX/PARCEL#-_ _ _ _ _ _ _ - _ _ _ _ PROPERTY OWNER NAME: AFH LICENSEE NAME (IF DIFFERENT): �Ca DAYTIME PHONE. DAYTIME PHONE: On a separate sheet of paper (8 1/2x 11) draw a floor plan (including all floors) of your prospective AFH. Include all sleeping rooms (bedrooms) indicating which bedroom is: A, B, C D, E and F. Label all components for exiting i.e., stairs, ramps, platforms, lifts and elevators. %I►'/'ad09.11.r&I KW 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 requesting or I am authorized by the owner of the above premises to request inspection for the operation of an Adult Family Home at this location. I agree to hold harmless the jurisdiction conducting such inspections, at my request, as to any claim (including costs, expenses, and attorneys' fees incurred in the investigation of such claim), which may be made by any person, including the undersigned, and filed against the jurisdiction, but only where such claim arises out of the reliance of the jurisdiction, including its officers and employees, upon the accuracy of the information supplied to the jurisdiction as a part of this applicatio . NAME/TITLE: W"'l ta DATE: �� 2 kWIZOPERTY OWNER MAI'11t,WANT Q LICENSEF. Implementation Date: 2024 March 15