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REQUEST FOR INSPECTION- Adult Family Home <br />APPLIGTIQN NUMBERC <br />ApplicanC must comple[e seccions 1, 2, 3, and 4. Application must be complete to be processed. <br />SRE ADDRESS: I � �.3� �Yl� 7� �-. � � ���� - -(��E� R'S TAX/PARCEL tt: - - - - - - - - - - - <br />PROPERTY OWNER NAME: �IG(JGIt-I L1 �N DAYTIME PF10NE: �� � i`��I��� <br />LICENSEENAMEpFoiFFeaeNr�: M74N5CC�A ��Ml�AUS%� DAYTIMEPHONE: 7�' �-�"�' /7"�S <br />� ��• <br />A comi�lete floor plan must include alI sleeping rooms, identified by number (;rl, #2, #3 etc.) and all components for <br />exiiinc;, i.e. stairs, ramps, platform lifts and elevators. (Attach additional sheets if necessary) <br />5 t � �11 i 1�i� i._k�,� '�] I��[ 'K ��l �1 �� <br />c'"- �`J <br />. � . <br />I certify under penalty of perjury that the informatior furnished by me is true and :.�rrect [o the bes[ of my knowledge, and that I am authorized by <br />the owner of the above premises to request inspeRion for and operate an Adult Family Home at this iocation. I further certify that I have made <br />applica[ion ro the Department of �ocial and Health Services and the jurisdiction fur the appropriate license(s) to mnduct such business at this <br />laation. I further agree to hold harmless the jurisdictiom m�ducdng suci� inspections at my request as to any daim (induding wsts, ezpens2s, and <br />attomeys' fees incurred in the invesiiganon of such daim), which may bz made by any person, induding [he undersigned, and filed against Ihe <br />juristlic[ion, but only where su�h daim arises ouc of the re!iance of [he jurisdiRion, including i[s o�cers and employees, upon [he accuracy of the <br />information supplied W the jurisdIiccion as a part of this applic [ion. <br />NAME/TITLE: ,""q^Q�'�` ��%"r�"�'�/ IUD✓1� DATE: �I"�!I�'�a` <br />_ PROPERTYOWNER \IAPPLICANT _ LICENSEE <br />