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Category 2:Sensitive information <br /> Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References: 2021 IRC Section R330 (WAC 51-51) <br /> APPLICATION NUMBER: <br /> r` SECTIONS 1. 2. 3,AND 4 MUST BE COMPLETED By APPLICANT BEFORE INSPECTION WILL 13E PROCESSED <br /> • —PROPERTY INFORMATION <br /> SITE ADDRESS: west f�w _ c/ �iC� ASSESSOR'S TAXIPARCEL#: 042QOd38 o <br /> • 2�.­`- PLICANT I N FORMATION <br /> PROPERTY OWNER NAME:.___,_�'Gtl�G(,s[n __...,Lc` DAYTIME PHONE: f 7� <br /> AH I LICENSEE NAME(If DIFFF.REt1T): C� JI.�A"k DAMME PHONE: <br /> ! • i ' PLAN <br /> An 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 ®, E and F. <br /> Label all components for exiting i.e., stairs, ramps, platforms, lifts and <br /> elevators. <br /> SECTION 4—PISCLA,IMER/SIGNATURE 13LOCK <br /> I certify Linder 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/e of the information supplied to the jurisdiction as a part of this application. a <br /> NAMEIT'ITLE:— - J}'GGlGf0VL' lit`. _— --------- ---.�..--- DATE: LJ{ <br /> WPROPERT'Y OWNEAt f3APPI.11CAN't- 13 LICENSEE <br /> Implementation Date: 2024 March 15 <br /> Updated: 2024 March <br /> Category 2:for official use only!disclosure permissible by iaw. <br />