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: SECTIONS 7 3,AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED • • ' • • • j SITE ADDRESS: Z?+ 12 3 4'h AC S6 evev'er-t W R 178'2o S II�DRSTAX/PARCEL#: • • PROPERTY OWNER NAME: (/TZQ rr, S DAYTIME PHONE: AFH LICENSEE NAME(IFDIFFEuiM: DAYTIME PHONE: SECTION • • • PLAN APPLICANT MUST DRAW COMPLETE FLOOR PLAN/s ON THIS FORM(AEL FLOOP.S). PLEASE INCLUDE ALL SLEEPING ROOMS(BEDROOMS). ON THIS DRAWING"INDICATE WHICH BEDROOM ISA B C,D,E,AND F. LABEL ALL COMPONENTS FOR EXITING Le.:_STAIRS, RAMPS,PLATFORM LIFrS&ELEVATORS, f �c .Fts�owe k@ Td\e 1 raovh/ �- 141.n8r9 rn i5Z}c, NS L � = _.. `- /4 T7f Z'Sic- 8�br Lt - - - vtr►g/ _Sttor�� Cera�e � �` _;,�,,;,z �ctu 'dam .� i _ �*►s/ �I j , C3c�Y-tiro r►�.� O VY• -tvile -S glq Y'6d c s Yo-a rte. SECTION-4— ! "MEk1S1GNATUJRE,8L0CK I certify under penalty of perjury that the information furnished by me is true and correct to the best of my knowledge,and the I am c-I am authorized by the owner of the above premises to request inspection for the cos-ration of an Adult Family Home at this loon_ I earer-to hc.`d harmless the jurisdiction conducting such inspections,at my request,as to any claim(ncluding casts,expenses,and attorneys'feia incurred in the investigation of such claim),which may be made by any person,incf•.rding the und=_rsigned,and filed against the jurisdiction,but only c*se such claim arises out of the reliance of the jurisdiction, including its officers and employees, upon the accuracy of the information su^_r�m to the jurisdiction as a part of this application. NAME/TITLE: �aSJY C--�/ �7'DGCT�GI�L� S DATE: 12— PROPERTY OWNER tJ APPLICANT ❑ LICENSEE d�°