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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 /> SECTIONS 1.2,3, AND 4 MUST BE COMPLETED By APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br /> SECTION • ' • ' + 1 <br /> SITE ADDRESS: GL1 (3 L S(~ ELCCf'lT C 1 -'(,r6 ASSESSOR'STAXIPARCEL#: GUClZt3 aC'0<�J lou <br /> SECTIONAPPLICANT { + { <br /> PROPERTY OWNER NAME: Rose-, C Ls r-C L-'T-Z/+Vc S DAYTIME PHONE:SC� <br /> AFH LICENSEE NAME(IF DIFFERENT): Sc'r t1 r: DAYTIME PHONE: �CtYY� <br /> SECTIONFLOOR 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 /> 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 <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. <br /> NAME/TITLE. �-(6012[2I-b S DATE <br /> EIPI�OPERTY OWNER EIA6LICANT ❑LICENSEE <br /> Effective:2013 July 01 <br /> Updated:2013 June 1I 2 <br />