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. 1 <br /> • � 1 <br /> • , � ( • � <br /> REQUEST FOR INSPECTION-Adult Family Home <br /> Arruunon NuMeen: <br /> Applicant must complete sections 1, 2, 3,and 4. Appliotlon must be complete to be procPssed. <br /> . • . • � • � I <br /> s�noor�ss:��0� SG'�CG��e..) I.��wl�_ ASSFSSOR'STA%lPAR�LR: _----_—�_--- ; <br /> � • ' /�,"�� � <br /> PROPERTY OWNER NAME: �`�`Y� 11 . ('�.{ 1 • • • � , � �C�!�E PHONE:�I•�) 3�'r �':i>3 I <br /> V�NS�NAME(�ov�ne,r- LL�y(1T �`I "f1AC1 DAMMEPHONE: �> >��� �4'�9 <br /> � • � . . <br /> A complete ioor pian must Indude all sleeping rooms,Identified by numbel(#1, #2, #3 etc.)and all components for <br /> exiting, i.e. stairs, ramps, platfortn lifts and elevators.(Attach additlonal sheets If necessary) <br /> � � � <br /> I crJtify under penalry of per�ury that the Infortnation fumisheA hy me Is We and rortect to the besc of my knwAe7g4 and thet I em autfioriad by <br /> the owner af the above premBes to rcquest inspection for and operah an Aduk Family Home at this locatlon. I further artify that.;:.ve made <br /> apptlotion to the Department of Sodal and Health Servicrs and the JurixdlNon tor the approprin[e license(s)In conduct surh busin�z:this <br /> Io¢tlon. I furMrJ agree to hold harmiess the�unsdiNom m�ducting suc.�inspections at my request as co any daim(induding costs,�enses,and <br /> attomeys'fees�narted In tfie Investlgatlon af such daim),which may be msde by any person,Induding the undersigncd,and filed agalnst the <br /> Jurisdiction,but only where such daim arises out of the retiance of the�urisdictlon,Induding its oficers and employea,upon the aca2q of the <br /> mfortnatlon supplied to Ne JurisdiNon as a part of tfiis appliotlon. <br /> NAME/TITI.E: ��,.�,����.,�, A./L�� — DAiE: �I /I�0 � <br /> '�PROPERTYOWNER O APPLICANT � LICENSEE <br /> 1I�, <br />