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Adult F ily Home (AFH) LOCAL BUILDING 1NSF L:L I1UN k-nC%.nLJLa I <br /> r -� eferences: 2018 IRC Section R330(WAC 51-—) 2f <br /> APPLICATION NUMB R: Frz�-of I _03J <br /> AND 4 MU BE COMPLETED BY APPLICANT BEFORE INSPECTION WILD BE PROCESSED <br /> SECTION —PROPERTY" • ' • <br /> -00 <br /> SITE ADDRESS: [ O 1 CO���n �Y ASSESSOR'S TAX/PARCEL#:_--___------ <br /> • APPLICANT INF• • <br /> PROPERTY OWNER NAME: DAYTIME PHONE: <br /> R4 _—_ <br /> AFH LICENSEE NAME([F DIFFERENT): G \ I � A DAYTIME PHONE:_ <br /> SECTION • • ' PLAN <br /> On a separate sheet of paper 8 '/2 x 11 draw a floor Ian includin all <br /> p p p ( ) p ( 9 <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 /> FEB 19 2023 <br /> ITY OF EVERETT <br /> Permit Services <br /> SECTIONBLOCK <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 iany 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 supplied to the jurisdiction as a part of this application; <br /> NAMEITITL,E: - ----_-- --- DATE:--__—_ _--•.-- <br /> QPROPF,RT1.OWNER DAPPLICANT DI..ICENSF.F, <br /> Implementation Date: 2021 February 01 <br /> Updated: 2021 February <br />