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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> (nAa Rafaranraa• <br /> 9n19 IR(`Rar*lnn 1:219g MAC:F4.r,1% <br /> APPLICATION NUMBER: <br /> SECTIONS 1.2,3,AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br /> SECTION 1—PROPERTY INFORMATION <br /> • <br /> A.SITE ADDRESS: I O0 �t PL. (Ss lIJ. EverettW 'a ASSESSOR'S TAXIPARCELtk - <br /> SECTION 2—APPLICANT INFORMATION <br /> PROPERTY OWNER NAME: t rI l IN/0at. DAYTIME PHONE: IBJ— " (SO.2 <br /> AFH LICENSEE NAME(IF DIFFERENT): DAYTIME PHONE: <br /> SECTION 3—FLOOR PLAN <br /> • <br /> /1rw ....<.“..•SA MA. 4•4111w war w1C r.n►wwv rep I 'As •1 41 1 oivn..a. — Viww.. wawa oft . 1 , .1, . ..fill <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 /> 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, <br /> NAME/TITLE: Spe'i t k A mem(a/ PYD YD V CAeA'" DATE: s 7 / 7 / 7 <br /> OprrtvrCtsIT vyyncrs IhiaHrrt.It,t r I V LI�+FIW7GC <br /> Effective:2013 July 01 <br /> Updated:2013 June <br />