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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 />� <br />SITE ADDRESS: �� � / C1 � � C l�V��� / �^�� �- ` �%� �a�� (�-- '��� �1 ASSESSOR'S TAX/PARCEL#:_'�� 1 ���_ _ <br />PROPERIY OWNER NAME: ,ri �t'� �� �����'� DAYTIME PHONE: 7�7• ��" 7� ��t�� fI / <br />AFH LICENSEE NAME (iF �tFFeReNr): <br />DAYTIME PHONE: �-/- % � � � t� � - � ��'� <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 />� �� � � <br />�' -� �' � <br />� �:� <br />� <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. l <br />NAMEITITLE: �l"I � �� ��5 i� �� �1 DATE: � � <br />Q PROPERTY OWNER �APPLICANT Q LICENSEE <br />Effective: 2013 July 01 <br />Updated: 2013 June <br />