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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 • e ' s • • <br /> SITE ADDRESS: I / I V+h 1) R\ SC- L)ef A t '' . <br /> �"\`� W� ASSESSOR'S7AX/PARCEL#: <br /> SECTION " • • <br /> PROPERTY OWNER NAME:ilk 6 kCAVX0 " �+�C�,+c.' lf�\ R✓��� DAYTIME PHONE:2o v b <br /> AFH LICENSEE NAME(IF oiFFeaerrr): M Y\ �u\� l� 11���DA�ITIMEPHONE:�-f-���vti � / <br /> 3E <br /> SECTION • • ' v <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 /> SECTION • BLOCK <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.. II <br /> NAME/TITLE:���VLO�VLCTl-+-1 �� _( Q_ [,.t i Gt K 17 L— DATE: <br /> XCPROPERTY OWNER APPLICANT 'LICENSEE <br /> • Effective:2013 July,01 <br /> Updated:2013 June <br />