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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 /> SECTIONPROPERTY INFORMATION <br /> SITE ADDRESS: 5611 COLBY AVE. EVERETT, WA 98203 ASSESSOR'S TAX/PARCEL#:00495580020-0600 <br /> • APPLICANT INFORMATION <br /> PROPERTY OWNER NAME: ADAN BALANGUE DAYTIME PHONE: 4255-344-9544 <br /> AFH LICENSEE NAME(IF DYFEREWn: ADAN BALANGUE DAYTIME PHONE: 425-344-9544 <br /> SECTIONPLAN <br /> On a separate sheet of paper (8 1/2 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 /> SECTIONBLOCK <br /> I certify under penalty of perjury that the information fumished 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. <br /> NAMEITITLE: RONALDO MACTAL DATE: <br /> QPROPERTY OWNER APPLICANT Q LICENSEE <br /> Effective:2013 July 01 <br /> Updated:2013 June <br />