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�>>I _�(:''> (���1 �� <br />Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br />Codc Refcrences: 2009 IRC Sectian R375 (WAC 51-51) <br />APPLiCATION NUMBER: <br />. __ _ . . . _ _ _ .._._ __ _ __.._ _—___ _ _ � <br />SECTIONS 1, 2, 3,.AfJD 4 MUST BE COMPLETEO BY APPLICANT BEFORE INSPECiION WILL BE PROCESSEO <br />• •�' �• � <br />sn�nuo��tss: ��IC� l2jih PLJ� EvC..t7 k�� yr�.�.�g ;.s�iti���nt;tnr:r,v;cu.= UU`11/�OCOOUIOU <br />NROPEHTV OPlflCH IlA141 : "JS•1 G'l-'Ou?!iqN. � t _ ___ _ _ .. . .. . ...____ _ _ DAV1It4E PHOI7E{� �l�-_fC=� l=� �' SO j �Si,:J -i/J:� <br />Afll LICEf$EE 1lAhif �i� ninn.iru� f1�YTItdE PN07F.: ____ <br />� ��• <br />APPLICANT MUST ORAW [OMPLETE FLOOR PLANIs ON TMIS FORM (ALL FLOORS). PI.EASE INCLUDE ALL SIEEPING ROOMS (B[OROOMS). <br />O�+ nns nann��n�� Iumtni[ tvinrri tirrHorna �s A B C D. [ A11D F. Lnur.� AU COF1P0!lE�ITS FOR EXITING I C'.' SiA1R5. <br />RAIdPS. PLATfnftFi I il I.S Fi I�.11 V/�7ORti_ <br />I /=loo( <br />�J ��I l � {� <br />I.XN��OH� �1 M `�(G��O�I�i <br />3 ° ' C <br />� U J <br />IUfh <br />/a��n <br />[loxl (�fG�ioon� �tl� <br />c oa[i /� �guM <br />ic;rcHCN <br />4iViN6 <br />(ZpOl�+ <br />D�n,n, Wunury <br />1 COrv\ I55lni:+ <br />iGo�`� <br />�jnJnGes <br />K� fcNrn <br />1,�,.^a'y <br />pin��j <br />�UpM �ih <br />j OUN^ <br />� Grr�a�� 6F 5 <br />1 <br />� r �OU� <br />�Ca1�JM I.�b <br />e a <br />/� j—� l <br />! 1 �S�eK.j( <br />���u�j ���roo.r <br />Pj�afOJ M <br />l� <br />(juth <br />(OO�LI <br />(i�Y h <br />�Uon+ <br />. . � <br />I crridy untler pcnairy ol peryirty Ihat V�c iNonnni�nn lurn�shed by me is hue and caimt to Iho bcs� oi my 4.nowirdge. and thal I, m roqucsl np w I <br />am rmR�����ed by :hr n,vnnr ol Uic a6ovo p�mmses tn rtrquest inspncbon lor Ihe opaation ol nn Atl�JI � nmey Home al �hix laal�on_ I ugrce lo ho'd <br />hmn�lCss Ihe �inisWCUon runduflinp such Inspttlions, , I my rrq�.mst. ns In any clnim (includ.ng co5i5, O�pensCS, end aflGrnoys' lees incunCd ui Vm <br />I������.t _�aUon ol su-h � Vi�ini, vrh.ch may be made by mp� pr�son uuluAinq Ihe undars��ncd, nnd I�led ngainst Ihe �urisd�et�on, bui mly �Nie�e such <br />�Ja�.m ;rr,r. out ol :h�� iu!�nnr.r ol Ihp Iurisd�cDon. u��dutbnq �Is olLct��s and amployees, upon Ihe nrcur;Icy ol Ihe Inlamation SUppl�ed Io Ihe <br />i��.� il:' cn tP� a 1'�a�i cl I'� �. n{ip'�f,'.Lnn <br />NAME/TITLE: �ZO��j c I`.l-�L'Ll._'N_�G1, 5___--____.__ DATE: __—.._j_I. ���� '_1 �- <br />❑ PROPERiY OWNER Q, APPIICANT ❑ LiCkNSEE <br />08101110 <br />