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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References:2012 IRC Section R325(WAC 51-51) <br /> APPLICATION NUMBER: <br /> SECTIONS 1. 2. 3. AND 4 MUST BE COMPLETED By APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br /> SECTION • ' • • <br /> SITE ADDRESS: --f-I(O Z +i,) L, j - E\yey-en LU4 �0 5'20,b <br /> TAX/PARCEL#: d�Q Z_I} bCJJ�O �0 b <br /> • APPLICANT O. • <br /> PROPERTY OWNER NAME: "d5 c, C� Q r0 ur2 A le- DAYTIME PHONE: S03—560 —S (0q <br /> AFH LICENSEE NAME(IF DIFFERENT): C'�X Yn Q_ DAYTIME PHONE: amQ <br /> SECTION • • ' PLAN <br /> On a separate sheet of paper (8 1/2 x 11) draw a floor plan (including all <br /> floors) of your prospective AFH. Include all sleeping rooms (bedrooms) <br /> indicating which bedroom is: A, B, C D, E and F. <br /> Label all components for exiting i.e., stairs, ramps, platforms, lifts and <br /> elevators. <br /> SECTIONBLOCK <br /> 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 <br /> am requesting or I am authorized by the owner of the above premises to request inspection for the operation of an Adult Family <br /> Home at this location. I agree to hold harmless the jurisdiction conducting such inspections, at my request, as to any claim <br /> (including costs, expenses, and attorneys' fees incurred in the investigation of such claim), which may be made by any person, <br /> including the undersigned, and filed against the jurisdiction, but only where such claim arises out of the reliance of the <br /> jurisdiction, including its officers and employees, upon the accuracy of the information supplied to the jurisdiction as a part of <br /> this application. nn <br /> NAME/TITLE: TTs.ck Ry-OUTZiWtiGI- DATE: I2 ' '31 I 1� <br /> IfdF'``QoROPERTY OWNER ffAPPLICANT 0 LICENSEE <br /> Effective: 2013 July 01 <br /> Updated:2013 June <br />