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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References: 2021 iRC Section R330(WAC 51-51) <br /> APPLYcATioN NUM13ER: <br /> SECTIONS 1. 2. 3. AND 4 MUST BE COMPLETED BY!APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br /> • 1��PAOPERTY <br /> INFORMATION <br /> SITE ADDRESS:_-_, Zf�-_.----- ASSESSOR'S TAXIPARCELA.do �u-_00 00 0 0 <br /> OJl G� Ti'A WA I`( -- —----- DAYTIME PHONE: <br /> PI2UPi RTY OWNER NAME: _.._I a _-�. a__ .___.._. _.__._—--------__-_-- <br /> AFN t_It[N5Ef NAMI:(rr utrrrriern f.__.-_.-_-.Sa+ Q.-•--------------------------------_--- DAYTIME PHONE: �•i�"�. _ <br /> On a separate shoe 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. <br /> BLOCK <br /> I 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 1 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 illy 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 Guth claim arises out of the reliance of the jurisdiction, including its officers and <br /> employees, upon he accuracy of the information supplied to the jurisdiction as a part of this application. t <br /> iVAA9i:r113 L1::_ 'Cl 'a� -- -- -- ------ ---- -- - - - l7A l'i?: � 2-O <br /> i"Itt01'ieltl 't111i't:i, �IAi'i'i.t( A1't �i.IC�ENSF.�. <br /> i Implementation Date: 2024 March 15 <br /> Updated: 2024 March <br /> E <br /> F, <br />