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Adult Family Home (AFH) LOCAL BUILDING INSPEMON CHECKLIST <br /> C References: 2018 IRC Section R330(WAC 51 <br /> APPLICATION NUMBER: B2401-012 <br /> SECTIONS 1. 2. 3. AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br /> SECTIONPROPERTY INF• ' • <br /> 7209 6th Ave W Everett, WA 98203 00708000004400 <br /> SITE ADDRESS: ASSESSOR'S TAX/PARCEL#: <br /> SECTIONAPPLICANT INFORMATION <br /> PROPERTY OWNER NAME: <br /> Eyerusalem Maird and Miraf Maird DAYTIME PHONE:(206) 372-5591 <br /> AFH LICENSEE NAME(IF DIFFERENT): DAYTIME PHONE: <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 /> D V[E <br /> IE <br /> MAR 2 0 2024 <br /> CITY 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 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, upon the accuracy of the information supplied to the jurisdiction as a part of this application. <br /> NA �TTTLE: Jose Per DATE: 1/9/2024 <br /> M-E <br /> PROPERTY OWNER IX APPLICANT Q LICENSEE <br /> Implementation Date: 2021 February 01 <br /> Updated: 2021 February <br />