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Q�U � G�j U U�- <br />REQUEST FOR INSPECTIOP7- Adult Family Home <br />APPLICATION NUMBER: <br />Applicant must complete sections 1, 2, 3, and 4. Applicatlon must be complete to be processed. <br />, •.• .• . <br />5910 IIeverl iane Everett Wa. 9A,203 280901001Q1200 <br />SRE ADDRESS: Y � ASSESGORS 7AX/PARCEL �: _ _ _ _ _ _ _ _ _ _ _ <br />• �• � <br />PROPERN OWNER NAME: �-'rndCClltd P'. Sarausad DAYTIME PHONE: ZOE—ZZ9—SOZ3 <br />BeeCee Hanes 206-?29-5023 <br />LICENSFE NAME ��r oirrra[Nrr DAVTIME PHONE <br />� •�• <br />A complete floor plan must Inciude all sleeping rooms, Identifed by number (#1, #2, �3 etc.) and all components for <br />exiting, i.e. stairs, ramps, pla[form IiRs and elevators. (Attach addilional shee[s if necessary) <br />Ylc•��se sce citt��ched sheels <br />I certify unAer penalty of pe�ury thal tlie miomiaGon fmm9�ee1 by me is tme and currect to Ihe be5t Of my knrnvledge, and lhat I am authonaei Oy <br />the owner of the albve prMni:cs ro requcst inspc�ctidi for and operate ar Aduit Family Mane at this laatloa I lurther mrtfy that 1 have made <br />apphGition to the Department ot Saial ancl Healtli Services anA tlie junsAicnnn for the appropnate hceise(s) to condud wch buvness at Ihis <br />Icxanon. 1 further agree to hokl h,vmless the Junsd�cUon conductiny wci� mspeclions at my request as m any daim Qnduding casts, erzpen5es, and <br />altnneys' fees incvned in (he inveslgaUun uf wdi daim), whidi may be madC by any person, inclutling Ihe undersigned, xid filed agalnst the <br />)unsA�ct�on, but nnly where uxh dalm an,es out of the reliarxe o( Ihe )urisclic4ai, indudiru� ds nffirnrs and employees, upon the aavracy of the <br />�nfnrmatwn ui�+{�hed to the �unsdipiwi as a V�rt of Uus aUP6cahon. <br />. . . . �..� ' �- <br />I3ernarclita C. Sar�ir=,�c��rresident � ;���/.. � <br />NAME/TITLE: DATE: <br />! PROVEHTYOWNER ✓ APPLICANT .' LICENSEE <br />