Laserfiche WebLink
� <br /> , <br /> _ Adult Farnily Home (AFH) LOCAL BUILDING INSPECTION CHECKLlST <br /> •� - - - -----.- -_ _. ..__.�._ _ _ __., _ __ _Coc(e References:2012 tRC 5ection R32b(WRC51_51j_.__.,__,__ <br /> ;J` APPLtCATION NUMBER; <br /> �`� SECTtONS 1.2, 3.AND 4 MUST 6E COMPLE7ED BY APPl1CANT BEFORE tNSPECTtON WILL BE PROC�SSED <br /> m " e ' e � � • <br /> n . <br /> S17EADDRESS:�:,s'�-s� ��� ��� �i�i/���G� ��A5SESSOR'STAXlPARCEL#:_______-__ <br /> � 1 . r � , . ! . <br /> PROPERTY OWNER NAME: 1 `�� �71, `'�'' f��';�"�} �r C�� DAYT2ME PHONE: �� ""� .`'�'j <br /> C� <br /> AFH LTCENSEE NAME(tF arF�rtr7:_<'/T-', � r� �i�� DAYTIME PHONE: �� �'�- ���~ <br /> � <br /> • • � ' � � <br /> On a separate sheet of paper (81/z x 11) draw a floor plan (including all <br /> floors) �f your prospec�ive AFH. Include all sleeping rooms (bedrooms) <br /> indicating�ititiich bedroom is: A, �, C D, E and F.� <br /> ..�- Label atl components for exiting i°e., stairs, ramps, platforms, lifts and <br /> elevators. <br /> � � � � , � <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 hy the owner af the above premfses to request (rispection for the operatlon of an Adult•Famfly <br /> Nome at thts locaYion. I agree to hofd harm(ess the jurisdiction conducting such InspecEions, at my requesfi, as to any daim <br /> (including cosFs, expenses, and attomeys' fees incurred in the tnvesHgatfon of such cfaim), whtch may be made by any person, <br /> Pncluding the undersfgned, and filed against the jurisdiction, but onfy where such claim arises out of the reliance of the <br /> jurisdicdon, inctuding its officers and empioyees, upon the accuracy of the Informa8on supplied to the jurisdlction as a part of <br /> thts app{ication,, <br /> NAME/TITLE: DA'fE, <br /> ❑PROPERTY OWNER �APPLICANT ❑LICENSEE � <br /> "�'' Effective:2013 July,01 <br /> Updated: 20131une <br /> � � --� ,� <br />