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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br />Code References: 2012 IRC Section R325 (WAC 51-51) <br />APPLICATION NUMBER: <br />� /vt.t) �1c: J'Z.� �v <br />�! �� �4 "l � `� � <br />SECTIONS 1. 2, 3. AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br />SECTION 1- PROPERTY INFORMATION <br />SITEADDRESS: �` �� ��� ���/� �f�t v L. /��� �����r�-� qSSESSOR'STAX/PARCEL#��_�J_L�������3 <br />SECTION 2 — APPLICANT INFORMATION <br />PROPERTY OWNER NAME:� 1�N t' I t G ��� �� I N� DAYTIME PHONE.� I`-F' ��� �+ �� � <br />AFH LICENSEE NAME (iF oiF�rrr�: r��"'� DAYTIME PHONE: <br />SECTION 3 — FLOOR 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 (6edrooms) <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 />I • . � . � . _ <br />I certify under penalty of perjury that the information fumished by me is true and corcect 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 inspecdon 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, eacpenses, and attomeys' 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. A <br />NAME/TITLE: �""��'��.I � � � � I C_.-� I C� � ��, ( - f �J <br />- DATE: <br />LTdPROPERTY OWIdER �APPLIC�ANT � LICENSEE <br />Effective: 2013 July 01 <br />Updated: 2013 June <br />