8909 CORBIN DR 2025-09-10 - Laserfiche WebLink

Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST Code References:2018 IRC Section R330(WAC 51-51) f APPLICATION NUMBER: SECTIONS 1,2,3, AND 4 MUST BE COMPLETED By APPLICANT BEFORE INSPECTION WILL BE PROCESSED SECTION I—PROPERTY INFORMATION SITE ADDRESS: U 1 D C 1,ah (/V rG'G� �VI 18 1�7A !70-- - ---- SECTION e SSESSOR'STAXIPARCEL#:_______ ____ • APPLICANT INFORMATION PROPERTY OWNER NAME: 2)6Lf1l ek I aQ_yyme h25 D DAYTIME PHONE: Fv 3J.9,1 5,� AFH LICENSEE NAME(IFDIFFEaEND: pRG C3L ht I� rl DAYTIME PHONE: J r S� SECTION • • ' PLAN On a separate sheet of paper (81/2 x 11) draw a floor plan (including all floors) of your prospective AFH. Include all sleeping rooms (bedrooms) indicating which bedroom is: A, B, C D, E and F. Label all components for exiting i.e., stairs, ramps, platforms, lifts and elevators. SECTIONBLOCK 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 requesting or I am authorized by the owner of the above premises to request inspection for the operation of an Adult Family Home at this location. I agree to hold harmless the jurisdiction conducting such inspections, at my request,as to any claim(including costs, expenses,and attorneys'fees incurred in the investigation of such claim), which may be made by any person, including the undersigned, and filed against the jurisdiction, but only where such claim arises out of the reliance of the jurisdiction, including its officers and employees, upon the accuracy ofthe information supplied to the jurisdiction as a part of this application. NAME/TITLE: 1Dar\i C. LNeI(\(\e-Y\ZS 0 DATE: o PIt�PERTY OWNER \LICANT 0 LICENSEE os� U Implementation Date: 2021 February 01 NOV 2 2 2023 Updated: 2021 February CITY OF E`IERETT Permit Services