Laserfiche WebLink
Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References:2012 IRC Section R325(WAC 51-51) (� p� (� <br /> APPLICATION NUMBER: '72 ( ( o -v <br /> 6 LI-c0 - 409 <br /> SECTIONS 1. 2. 3.AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br /> SECTION 1—PROPERTY INFORMATION <br /> SITE ADDRESS: I 07 A L 6 L. r< AVE--- <br /> V ` ASSESSOR'S TAX/PARCEL#: <br /> SECTION 2—APPLICANT INFORMATION <br /> PROPERTY OWNER NAME: L hl � � Cil f-e DAYTIME PHONE: 4°2 °J Dy <br /> AFH LICENSEE NAME(IF DIFFERENT):_ Vt/l-t>i fH DAYTIME PHONE: fir <br /> _ cr9 o e <br /> SECTION 3—FLOOR 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 /> 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 claim), which may be made by any person, <br /> including the undersigned, and filed against the jurisdiction, but only where such claim arises out of the reliance 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. _/ /��, j f <br /> NAME/TITLE: 5/ t t- /"/^ W/ Z /j frh i/ate DATE: //— 2/' <br /> I PROPERTY OWNER DAPPLIICANT EILICENSEE <br /> Effective:2013 July 01 <br /> Updated: 2013 June <br />