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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: <br /> SECTIONS 1, 2, 3, AND 4 MUST BE COMPLETED By APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br /> SECTION • ' • ' • <br /> 00398700200402 <br /> 2309 74TH ST <br /> SITE ADDRESS: , EVERETT, WA 98203 ASSESSOR'S TAX/PARCEL#: <br /> SECTIONAPPLICANT • . • <br /> PROPERTY OWNER NAME: � M PA DAYTIME PHONE.2OL- 8!1 8-`O`L <br /> AFH LICENSEE NAME(IF DtFFeRerrr _ ��i.rJ P �j �2— DAYTIME PHONE: <br /> SECTION • • ' PLAN <br /> On a separate sheet of paper (B 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 4- DISCLAIMER/SIGNATURE 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 /> Imes upom Hie accuracy of theto the jw indiction as a pai t vHyis-appficfttioti- <br /> \TAMF/ — <br /> 011ROPERTY OWNER DAPPLICANT 0 LICENSEE <br /> Implementation Date: 2021 February 01 <br /> Updated: 2021 February <br />