Laserfiche WebLink
Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References: 2018 IRC Section R330(WAC 51-51) <br /> APPLICATION NuMOER: <br /> SECTIONS 1, 2, 3, AND 4 MUST BE COMPLETED By APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br /> SECTIONPROPERTY • • • <br /> SITE ADDRESS: L O C'0� N r C,.A/e WV "/ l SSESSOR'S TAXIPARCEU: O S 1�Iyoonn7Da <br /> _______ ---- <br /> SECTION 2 APPLICANT • . • <br /> PROPERTY OWNER NAME: •Darei eZ I G�2W�-�QS D DAYTIME PHONE: D �`� ✓�� <br /> loll I/. <br /> AFH LICENSEE NAME(IFOIFF�rrn: ( �L Ll��i _ DAYTIME PHONE: A 5 — S U ;7; <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 /> SECTIONi • <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 tills 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, upo^ the accuracy <br /> ll of the Information supplied to the jurisdiction as a part of this application. <br /> NAMI%IIITLL' nA"fl:: <br /> I- Q11ERTY OWNLIt APPLICANT ICENSI•:1? <br /> a U <br /> Implementation Date:2021 February 01 <br /> NOV 2 2 2023 Updated: 2021 February <br /> CITY OF EVERETT <br /> Permit Services <br />