Laserfiche WebLink
Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References: 2018 IRC Section R330(WAC 51-51) <br /> APPLICATION NUMBER: <br /> SECTIONS 1, 2, 3.AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br /> SECTIONPROPERTY INFORMATION <br /> SITEADDRESS: ! {�1 IV ASSESSOR'S TAX/PARCEL#: <br /> --------____ <br /> • APPLICANT • 4 • <br /> PROPERTY OWNER NAME: � � K DAYTIME PHONE: (� Z� 07 2� <br /> AFH LICENSEE NAME(IF DIFFERENT:, (� �-� L)N I DAYTIME PHONE: J <br /> SECTION • • ' PLAN <br /> On a separate sheet of paper (81/2 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 /> D IECEOVE <br /> MAY 11 2024 <br /> CITY OF EVERETT <br /> Permit Services <br /> SECTION • BLOCK <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 ,suupplied to the jurisdiction as a part of this application. r j <br /> NAME/TITLE: ��// c-) IV I `� K i DATE: 1 13 I Xj <br /> 13PROPERTYOWNER 13APPLICANT 13LICENSEE <br /> Implementation Date: 2021 February 01 <br /> Updated: 2021 February <br />