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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br />Code References: 20181RC Section R330 (WAC 51-51) <br />APPLICATION NUMBER: <br />SECTIONS 1. 2. 3. AND 4 MUST BE COMPLETED By APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br />SITE ADDRESS: <br />SECTION 1— PROPERTY INFORMATION <br />1410 73RD ST SE EVERETT, WA 98203 <br />PROPERTY OWNER NAME: <br />ASSESSOR'S TAWARCELM 00472300001500 <br />SECTION 2 — APPLICANT INFORMATION <br />SAMUEL ALEMU <br />AFH LICENSEE NAME (IF DIFFERENT}: <br />SECTION 3 — FLOOR PLAN <br />DAYTIME PHONE: 206-766-0570 <br />DAYTIME PHONE: <br />On a separate sheet of paper (8 1/2x 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 4— DISCLAIMER/SIGNATURE 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 <br />Home at this location. I agree to hold harmless the jurisdiction conducting such inspections, at my request, as to any claim <br />(including costs, expenses, and attorneys' fees incurred in the investigation of such daim), which may be made byy any person, <br />including the undersigned, and filed against the jurisdiction, but only where such claim arises out of the rellante of the <br />jurisdiction, including its officers and employees, upon the accuracy of the information supplied to the jurisdiction as a part of <br />this application. <br />NAMEITITLE: Samuel Alemu DATE: <br />,PROPERTY OWNER ©APPLICANT Q LICENSEE <br />02/05/2025 <br />Implementation Date: 2021 February 01 <br />Updated: 2021 February <br />