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(Alegory 2: sensitive information <br />1dult: Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br />Code Rererencess,2.921 IRC Settlon R330 (WAC 51-51) <br />APPLICATION NUMBER: F32412-034 <br />.�.— <br />SECTIONS 1. 2. 3. AND 4 MUST 13E COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br />SITE ADDRESS: 215 11 OTH PL SE <br />ly <br />N 1 -- PROPERTY INFORMATION, <br />ASSESSOR'S TAXIPARCEI-#-- <br />SECTION 2 — APPLICANT INFORMATION <br />PROPERTY OWNER NAME: _-- -_ Lot) <br />AFH tICENSEE NAME (wotrfEREtM: <br />SECTION 3 - FLOOR PLAN <br />DAYTIME PHONE <br />DAYTIME PHONE: <br />On a separate sheet of paper (8 112 x 1.1) draw a door plan (including all <br />floors) of your prospective AFH. Include all sleeping rooms (bedrooms) <br />indicating which bedroom is: A, B, C D, F and F. <br />Label all components for exiting i.e., stairs, ramps, platforms, lifts and <br />elevators. <br />lop <br />I ceriify 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 the undersigned, <br />and filed 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 applicatio . <br />I Inl�ral irr.I:: _ _ 1e'f UU _ _ __.... __..__-.... vn rl.: _' <br />11, <br />>Itr>rl;rrrvl WNEIR 13APPLICANT 13 LICENSEE <br />Implementation Date: 2024 March :kS <br />