2216 127TH PL SE 2017-06-07 - Laserfiche WebLink

Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST Code References: 2009 IRC Section R325(WAC 51-51) APPLICATION NUMBER: "5 3 SECTIONS 1,2,3,AND 4 MUST BE COMPLETED By APPLICANT BEFORE INSPECTION WILL BE PROCESSED SECTION • • • • SITE ADDRESS: 2ZI (c 171 f1l PL 5C, EU6_12f77 '-JA g62CB ASSESSOR'STAX/PARCEL#: 00 921 9 00000 /OO SECTION • • PROPERTY OWNER NAME: OSO 13 aaU 1 Z A le-1-S )j DAYTIME PHONE: 50 -SEu- 3 1 OCI AFH LICENSEE NAME(IF DIFFERENT): C'vvl rN l y�S ton�; �e(YH (Lt{� 'rv„�y // DAYTIME PHONE: ski►)� SECTION • • APPLICANT MUST DRAW COMPLETE FLOOR PLAN/s ON THIS FORM(ALL FLOORS). PLEASE INCLUDE ALL SLEEPING ROOMS(BEDROOMS). ON THIS DRAWING, INDICATE WHICH BEDROOM IS A, B, C, Q. E, AND F. LABEL ALL COMPONENTS FOR EXITING i.e.: STAIRS, RAMPS, PLATFORM LIFTS&ELEVATORS. 1V-1 F100c Ln un It i 7CHE^' LiLdA5 Dey J. too v+i BEJ2ooM eM " G gc�tZoOwl 13�pt2oo� 3 � _ E 6Anii6es i 13 rkV �7 A ,w oZ` not l ooY g�xroor-� { 3�raon-� BAth Z C .B�roow. (3ec�roo Gft2f�b6�s coo n-, E roo.� • BLOCK I 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 requesting or I am authorized by the owner of the above premises to request inspection for the operation of an Adult Family Home at this location. I 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 to the jurisdiction as a part of this application. ��S �nQ � T A S NAME/TITLE: DATE: /S PROPERTY OWNER .r-f APPLICANT ❑ LICENSEE _ 08101110