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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 /> r SECTIONS 1, 2, 3, AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br /> SECTION • ' • ' 1 • <br /> }� <br /> SITE ADDRESS:�y©�.S W�'�--:��� y tl`w - ASSESSOR'S TAX/PARCEL#:_kC_� <br /> SECTION —APPLICANT • ' + • <br /> PROPERTY OWNER NAME: �O'" / DAYTIME PHONE: <br /> AFH LICENSEE NAME(IF DIFFERENT): `" `} DAYTIME PHONE: �"' "' � <br /> SECTION • • ' PLAN <br /> On a separate sheet of paper (8 '/z 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, F and F. <br /> Label all components for exiting i.e., stairs, ramps, platforms, lifts and <br /> elevators. <br /> SECTIONIL <br /> DISCLAIMER/SIGNATURE BL <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 juris ion as a part of <br /> this applicatio <br /> NAME/TITL DATE: <br /> ®PROPERTY OWNER APPLICANT ❑LICENSEE <br /> Effective:2013 July 01 l/ <br /> Updated:2013 June f <br />