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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References:2OZ IRC Section R330(WAC 51-51) <br /> APPLICATION NUMBER: <br /> C C/`TI00,I4Z 1 7 1 Amn A AAI ICT or:rMADI FTGn nv ADDI irANIT mccr%DF 1A1CDF!`T1n FJ WII I LAC Dianrr:ccrn <br /> SECTION PROPERTY • • <br /> SITEADDRESS _LSvv ln�tk�' SC Gl�i'+ � WPJ _ ASSESSOR STAXIPARCELA 0003$•oDoWOO <br /> SECTION • ' • <br /> PROPERTY OWNER NAME:--b4I7 0n �Y1 f&0—Wlla& DAYTIME PHONE: <br /> AFH LICENSEE NAME(:F o:FFEFENT): a�uWvLk �--ZrA _ _ DAYTIME PHONE: �LS'137,5 °� <br /> SECTION • • ' PLAN <br /> On a separate sheet 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 /> SECTION • 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 <br /> 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 <br /> 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 <br /> undersigned, and filed against the jurisdiction, but only where such claim arises out of the reliance of the jurisdiction, including <br /> its officers and employees, upon the accuracy of the information supplied to the jurisdiction as a part of this application. <br /> ,'VAJ1E17'1TEE; DaTE: <br /> zk%�� <br /> ROI'F.RTY 011'NI.W El.1 hII'a.Y"1' Q IJCENSEE <br /> Implementation Date:2024 March 15 <br /> Updated: 2024 March <br /> ---------------------------- <br /> Scanned with <br /> m CamScanner <br /> ............................. <br />