2216 127TH PL SE 2016-09-14 - Laserfiche WebLink

Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST Code References: 2009 IRC Section 8325(WAC 51-51) APPLICATION NUMBER: SECTIONS 1,2,3,AND 4 MUST BE COMPLETED By APPLICANT BEFORE INSPECTION WILL BE PROCESSED SECTION • t' t • • SITE ADDRESS: 2,7 /29''K 12c s &-ve-ret w 17is 8 ASS ESSORSTAYfPARIFL#:----------- t •' -QRMATION PROPERTY OWNER NAME: UTza''r' % DAYTIME PHONE: AFH LICENSEE NAME of o>F TPEN'i: DAYTIME PHONE: SECTIONFLOOR APPLICANT MUST DRAW COMPLETE FLOOR PLANIS ON THIS FORM(A!L FLOORS). PLEASE INCLUDE ALL SLEEPING ROOMS(REDROOMS). ON THIS DRAWING INDICATE WHICH BEDROOM TSA B C D E AND F. LABEL ALL COMPONENTS FOR EXITING i.e.: STAIRS, RAMPS, PLATFORM LIFTS St ELEVATORS. — t Ll Vin shove K� �4rer� room/ Lat�Na�y - --- --- - l = � J(in.cI!;. NS / G ' - - i TYp�5 oc cro ,� �iVr+,g/ �:stitat� gCDfoowt j ;, � I Gr.��a cue Lao day f NS f t iC3C..'fl�tro�rM� We -S rlYoe ae1j 8 tk fib_ I certify under penalty of perjury that the information furnished by me i;true and camrwt to the best of my imovAedge,and dtaj f asn:=T. f-a o-t am authorized by the owner of the above premises to request inspection for the conation of an Adult Family Home at this lo-E'cn_ i asr°r fo ec'd harmless the jurisdiction conducting such inspections,at my request,as to any clam Including costs,expenses,and attorneys'fes;incurred in the investigation of such claim),which may be made by any person, inc!uding the undersigned,and fled against the jurisdiction,but cniy such claim arises out of the reliance of the jurisdiction, including its officers and employees, upon the accuracy of the information su^_r'e:j to the jurisdiction as a part of this application. NAME/TITLE 62aS�r C. �a?J�YT?�rvu S DATE: :) CTPROPERTY OWNER LI APPLICANT ❑ LICENSEE _ � ,J U�14