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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br />Code References: 2012 IRC Section R325 (VVAC 51-51) <br />APPLICATION NUMBER: <br />SECTIONS 1, 2, 3, AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br />SECTI�N 1— PROPERTY INFORMATION <br />SITE ADDRESS: ����7 G�,�:QS � Y e L��l � 7 � ASSESSOR'S TAXlPARCEL#:U fl�-� �(�'`�`j r' <br />i���-�`' <br />• 1• � •� � • <br />Cj C'� <br />.�°�-� ���1-� L C�: ���.s�-��� � <br />PROPERTY OWNER NAME: .���/`(����q 1f1 I cS S-l� ,Yi DAYTIME PHONE: I� J.�.c����� � � f l <br />AFH LICENSEE NAME (ff oi��rrr�: �-7�i�^t�� DAYTIME PHONE: <br />------ _ _.._ --- - ------ – -----__—_ __ ---- ---_—.__------ -- ------ __ _ ,. .-- --- --- <br />SEGT[ON 3 - FLOOR PLALIL ; � . ___ - <br />___ On a separate sheet of paper (8 �/2 x 11) draw a floor piarr (including all ____ <br />fioors) 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 />_ _- - _ _---- -- 5 --- — -- - .- - - -- <br />_ <br />` _ ' - - EGTION 4= DISCIAIMER/SIGN�ITURE BLOCK ` ` <br />I certify under penalty of perjury that the information fumished by me is true and correct to the best of my knowledge, and that 1 <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 daim <br />(induding costs, expenses, and attomeys' fees incurred in the investigation of such daim), which may be made by any person, <br />induding the undersigned, and filed against the jurisdiction, but only where such daim arises out of the reliance of the <br />jurisdiction, including its officers and employees, upon the acaracy of the information supplied to Uie jurisdiction as a part of <br />this applica6on. <br />NAM -� ' DATE: � 07 ���� <br />�ROPERTY OWNER QAPPLICANT Q LICENSEE <br />Effective: 2013 July 01 <br />Updated: 2013 May <br />