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Adult Familly Horne (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Cute References: �;,16'.;Zr-SecaDn R330 WAC 51-51 i <br /> APPI3CATIDN NUMBER: <br /> IDS 1. 2.3. 144D.4 W.-ST BE C2 'LETED BY APPLK:ANT BEFDRE NSPECTIDN WILL BE PROCESSED <br /> SI TE ADDRESS ,iG�I Y I Pui ASSESSOR S TAX,PARCELSQ26D—;!R0a L� <br /> SECTION • • • <br /> l <br /> PR�F,7v OWN_F.NAME: yA ov.,is . �Ykv'�l DW i"!_PHDNE: zo 7 3 Der <br /> AFF..UCENScE Nk%E(:f D-.1 7 <br /> On a separate sheet of paper (8 1/z 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 /> c `r .rrx;✓r ,F pv xy tr.. "u-se i7formejon furnished by me is true and correct to the best of my knowledge, and that I am <br /> or I am --exized by H-e owner of the above premises to request inspection for the operation of an Adult Family Home <br /> ett��riti^ . I to MM harmless tfie jurisdicti3n conducting such inspections, at my request, as to any claim (including costs, <br /> and axu.,_,:,'fees incurred in the imesti^yabon of such claim), wh',ch may be made by any person, including the undersigned, <br /> arr: fi✓d ag nst the jurisdiction, but only where such dam arises out of the re:iance of the jurisdiction, including its officers and <br /> e-Ope--es, c.pw the alr.. ar-Y of the iinforma'.ion supplied to the jurisdiction as a part of this application. Q <br /> NAMUTITLE: 'i �/I 1� �rG` �y DATE: ( L <br /> AlYROPERTYOWN"ER ❑APPLICANT LICENSEE <br /> Implementation Date:2021 February 01 <br /> Updated: 2021 February <br /> MCamScanner <br />