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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br />Code References: 2012 IRC Section R325 (WAC 51-51) <br />APPLICATIONNUMBER: �� f /CJ l _� ` <br />SECTIONS 1, 2, 3. AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br />SITEADDRESS: �� ��1�':'7 �� �' ;I V �- '��� ti� 1�����t� �`�� ��A SESSOR'STAX/PARCEL#:_______-____ <br />PROPERTY OWNER NAME: `� �� � ��r— �—'���"a ��'v� DAYTIME PHONE:!���% �-�����_�� <br />,^ �,� <br />AFH LICENSEE NAME �tFotFFERENr�:�. ������� �-�'��k���'� DAYTIME PHONE: ��l' ��������5� <br />On a separate sheet of paper (8 '/z 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 iocation. 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. <br />NAME/TITLE: �`.l I � � �-7i���� DATE: �' �"` � U!� / L <br />�PROPERTY OWNER �APPLICANT � UCENSEE <br />Effective: 2013 July 01 <br />Updated: 2013 June <br />