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Adult Family Home (AFH) LOCAL BUILDING IC:C4ECTION CHECKLIST <br />Code References: 2U09 IRC Section R325 (WAC 51-51) <br />AppLICATION NUMBER: <br />ASSESSORSTNf/PARCEL#: _ _' _ _' — _ — _' <br />DAITIME PHONE: <br />PROPERTY OWNER NAP1[: <br />DAYRME PHONE: <br />AFH I]CENSEE NAME OF o��aeirt): <br />ApPLICANT MUST DRAW COMPLETE FLOOR PLAN/5 ON THIS FORM (ALL ROORS�. PLEASE INGLUDE ALL SLEEPING ROOMS (BEDROOMS�. <br />ON TNISORAWINC� IN�ICATE \NHICH REDR0011 IS A B C D E AND F LABEL ALL COMPONENTS FOR EXITING I 2.: STAIRS. <br />RAMPS PLATFORM LiFfS & FLEVATORS. <br />I certily under penalty of perjury �hat the inlormation Wrnished 6y me is lrue and correcl to the hesl ol my knowledge, and ihat I am requesling a I <br />am authorized by the owner ol the above premises to request inspection for the operalion ol an Aduit Family Home at this Iocaiion. I a�ree to hold <br />harmless Ihe jurisdiction conducting such inspections, at my request, as to any claim (including cosls, expenses, and a:torneys' fees incurred in the <br />investigation ot such claim�, which may be made by any person, including the undersigned, and filed againsl lhe jurisdiction, but only where such <br />claim arises out ol the reliance oi the jurisdiction, inciuding its oflicers and employees, upon ihe acaracy ol the inlamation supplied to the <br />jurisdiction as a part ol this application. � <br />DATE: <br />NAME/TITLE: <br />❑ PROPERTYOWNER ❑ APPLICANT ❑ LICENSEE <br />08101110 <br />