810 89TH ST SE 2018-01-02 MF Import

REQUEST FOR INSPECTION- Adult Family Home APPLICATION NUMBER: Applicant must complete sections 1, 2, 3, and 4. Application must be complete to be processed. SITE ADDRESS; 81 O ' '1 cST ' SC _ ASSESSOR'S TAX/PARCEL =: e017'z9 3OCYJD �' FLOOR PLAN I A complete floor plan must include all sleeping rooms, identified by number (# 1, #2, #3 etc.) and all components for exiting, i.e. stairs, ramps, platform lifts and elevators. (Attach additional sheets If necessary) eAfe ecdtds Sheet s ■BLOCK 1 certify under penalty of perjury that the Information furnished by me is true and correct to the best of my knowledge, and that I am authorized by the owner of the above premises to request inspection for and operate an Adult Family Home at this location. I further certify that I have made application to the Department of Social and Health Services and the Jurisdiction for the appropriate license(s) to conduct such business at this location. I further agree to hold harmless the Jurisdiction conducting such inspections at my request as to any claim (including costs, expenses, and attorneys' fees incurred In the investigation of such claim), which may be made by any person, including the undersigned, and filed against the Jurisdiction, but only where such claim arises out of the reliance of the Jurisdiction, including Its officers and employees, upon the accuracy of the information supplied ttoh,� o the jlNca urnic assaa par f this application. '\ NAMEIMLE: !c_ "' DATE: Xlt�AOPERTY OWNER �UCENSEE