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• <br />� <br />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 />• • � • � • � � <br />/� �` oo�3Q�3�5aa3 0 0 <br />. <br />SITEADDRESS: I�� � ���S 7"\�% U R�� �'F.y �l' �' ASSESSOR'STAX/PARCEL��:_______-____ <br />• � ' � � � � � <br />PROPERlY OWNER NAME: � Cl'�0���� 1'���G Y� � S S�YI DAYfIME PHONE: ���^ �v�� 6-L �/ <br />`�JQ.� 6 �- �,�, C�=� � 1Qs� � -� �,5�,.�,d � w�� � �. <br />AFH LICENSEE NAME (iF oiFFeRerur): <br />DAYTIME PHONE: <br />On a separate �heet of paper (� 1/2 x�1) draw a floor plan (incl�ding all <br />floor�) of your prospe�tive AFFio an�1�d� �II �le�pin� r�orn� (b�dr��m�) <br />ondic�ti�g �rhich bedroorrt i�o A, �, C D, � a�d �o <br />Label all cornponents for exiting i.e., stairs, ramps, platforms, lifts and <br />elevators. <br />I• � � . ' ' <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 fi�ed against the jurisdiction, but only where such claim arises out of the reliance of the <br />jurisdiction, including its officers and emplo ees, upon the accuracy of the information supplied to the jurisdiction as part of <br />this app <br />NA /TITLE: ' DATE: � O �J O � � <br />�.PROPERTYOWNER ❑APPLICANT ❑LICENSEE <br />/ � <br />Effective: 2013 July 01 <br />Updated: 2013 June <br />