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APPLICATION AND INSPECTION CHECKLIST- Aduit Family Home <br /> Code RHennces: 200E I0.0 Sectlon N325(W�C Sl•51) <br /> AVVLICATION NUMBER: <br /> j _ . ___ SECilON51,2,3, AND 4 MUST BE CUMPLFTED BV APPUCMR BEfORE INSPECTIGN Wll.l BE PRpCfSSED __ __� <br /> __ ._ _ . . _ __ __ , . . � . � • � � <br /> ; � �, f � '� , � �l,• ' y - <br /> SITCAUDI�[ti5: � � �'___ � `"__ __ _ tSG5V1NS1�YiGARQU:_iL�G.7L�l1'L.S4�`�C(� <br /> � . . . . . � • � � � <br /> _ . , . ., <br /> �� .. - � <br /> . .. ^ <br /> PROM�NiVOY/NFRN�Mf�. ! , . ._� • . . ,. . _. _. UAVfIMSM10NE�. �- Iri__ ' . ' <br /> _ . - _ . _ _ ____-_ _ . __ _ <br /> '� _ .. y . o ' . . • <br /> Ill fNSfF NAMf rn onnc�r�i� ___._ __ UAVIIMF. PM(NJl.:�_,__�.____ ___ <br /> � � � . . <br /> APPLIGNT MUST DRAW A COMPLETE FIOOR?lAN ON THIS FORM. PLEASE%NCLUOE ALL SIEEPING NOOMS(BEONDOMS�. <br /> •�ON THlS bRAWlNG.TME lWLDIj��]j(,�PjGIQ$.ZSSI,�T THEN ILh_NTIry WHICH R�IOM IS SL!EPING ROOM #1. Z. 3.4. $.AP'�6"�vo <br /> �ABEL ALL COMPONENTS IOR EXfI INC 1 f �*AIRS ReMPS PLaTFORM LFT�&ELEVgI�BS,(USE 111CN Oi iH[S v11nER If Y0u NlEU MOAE ROM�) <br /> . � � <br /> � � 1 <br /> T <br /> / � <br /> , , <br /> , <br /> � . � <br /> I rivtity��ndih p�,n.ilty u� p��qmy Ih.n ib,� ����.n,i.tlmn�une�hirf by m��is hur and r.�vrn.l ln Ihr 6n5�ol my krwwlcM9c,nnd Ihal I am�iquc5tmg or l dm <br /> euthont��J Ly Ihr nwner ul Ihr nhnvr �,�..��r�;.,•�;ro uv7���"'I n,;pi.l�nn loi Ihr uperetiun ul �n Aitt.11 Family Nortie At Ilns Incalinn I lurthvr cMNy Ihnl I <br /> hdvr m;Idr :yX�hcaliUn�U Ihe C1CpJ�bnP�ii ul tiiy'r,il n��d Hrzllh St+viu5 hr :1n i�iull f;�nuly honte hcn`SC aid Ihdt I hqve al5o mNde ep01iCPUon lo Ihe <br /> ripp6cable �unsdx:Uoii �a Ihc a�qxiqm�tc IrcnsMsl b r.a�rnicl such M�siness al th�s Ixation I IpflhC� AQ�OC N hUld hAfTIQ55 Ih0 �UfISUICIIqt <br /> r.nndi�ctlng s�mh msperlions. al my rcyutMt.ns la nny claim�inchiding cosls.etpensos,erd atluneys'�ees iocuned in Ihe investgelwn ol such clxim�, <br /> whx�h mFly be�maAe hv a��y pasa�.inr.hxhny Iho undo�sgnec, nnd�iled againsl lhe jurisdclion,bul onlv where such claim arisos oul o�Ihe roliance o� <br /> Ou•pmsd�cLn�� u�rLiA�nq its nthce�s and enyilnpees.upu�tlie�cnnacy M the ndamation aiqplied to Ihe�unsdc6on es a pnrt d Ihre eppl�catim <br /> .. , ; .. ' , . . . i �• , � ,, , <br /> NAME/Ti7LE. . <br /> _ � . _. . � .. -- - . ... ---- --- _ _- DAT[: �" - -- <br /> ❑ PROPERTYOWNER L� RPPLtGNT � UCENSEE <br /> 811109 <br />