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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:B2408_012 <br /> -SECTIONS 1.2.3.AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL,BE PROCESSED <br /> SECTIONPROPERTY" • ' • <br /> SITE ADDRESS:_39(10 RTH AVF W FVFRFTT WA 9g2f)4 ASSESSOR'S TAWPARCEL#: <br /> SECTION —APPLICANT INFORMATION <br /> PROPERTY OWNER NAME: jLwyle_, z> DAYTIME PHONE: <br /> lie ILA r' <br /> AFH LICENSEE NAME(IF DIFFERENT): � � � DAYTIME PHONE: 3 (j <br /> SECTION • • PLAN <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 /> SECTION aBLOCK <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 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 applicatlan <br /> l,5� <br /> NAMF./T1TLE: Z f DATE: <br /> QPROPERTY OWNER QAPPLICANT 0 LICENSEE <br /> Implementation Date: 2024 March 15 <br /> Updated: 2024 March <br /> Category 2:For official use only/disclosure permissible by law. <br />