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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References:2018,IRC section R330(WAC 51-51) <br /> APPLICATION NUMBER: 'a�,A 4 OA — ©�� <br /> SECTIONS 1.2.3.AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED ; <br /> 4 <br /> 1 <br /> SECTION 1 — PROPERTY INFORMATION <br /> SITE ADDRESS: 6001 BROADWAY AVE EVERETT ASSESSOR'S TAX/PARCEL#_28050500201400 � <br /> SECTION 2—APPLICANT INFORMATION <br /> I <br /> I <br /> PROPERTY OWNER NAME: <br /> TEFERA EYASU&BEYENE BILEN DAYTIME PHONE: 4259740287 <br /> _ _ <br /> AFH LICENSEE NAME(IF DiFFEaEW MT BAKER VIEW ADULT FAMILY HOME LLC DAYTIME PHONE: 425 974 0287 <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. saUE <br /> 0 R <br /> AUG 19 2024 FEB 2 3 2024 <br /> CITY OF EVERETT CITY OF EVERETT <br /> Permit Services Permit Services <br /> SECTION + DISCLAIMER/SIGNATURE BL <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 incurr(7 he Investigation of such claim), which may be made by any person, including the undersigned, <br /> and filed against the jurisdiction, bt 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 application. <br /> a <br /> NAME/TITLE:_I lf'117. �i f'�`'L DATE: .C, ' <br /> EIPROPERTY OWNER 0APPLICANT LICENSEE <br /> i <br /> I <br /> Implementation Date:2021 February 01 <br /> Updated: 2021 February <br />