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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References:2072 IRC Section R325(WAC 51-51) <br /> APPLICATION NUMBER: <br /> SECTIONS'I,2,3.AND 4 MUST BE COINPL�-fED BY APPLICANT BEFORE INSPEC710N WILL BE PROCESSED <br /> � . . � . . � � r • <br /> srrE nnorz�ss: �r'; � �++V �����:.t �'`� �ttii rr ����'✓i l i� ASSESSOR°S TAXlPARCEL#���������G'c L�� <br /> � , . . j � . , � <br /> PROPEKTY OWNER NAME:_ _ �'� � if/'`C���i. t � i��� DAYTIME PHONE: �PJ� �TJ '� �J.� �� <br /> ARi LICETISEE NAME���ear): ��S-C��Q VI P W �'Cv p�. � �-�P t�'�A DAYTIME PHONE: � '�`�``�°' �S c-`'� <br /> • ! � • ` + <br /> On a separate sheet of paper (8 �/2 x 11) draw a floor plan (including ail <br /> floors) of your prospective AFH, Include aIl sleeping rooms (bedrooms) <br /> indicat�ing which-bedroom is: 1� B, C D, E and F. <br /> Label all components for e�dting i.e., stairs, ramps, platforms, lif�-s and <br /> elevators. - <br /> • � � 1 . � <br /> I ce�bfY u�der penalty of perjury that the irrtormahion fumished by me is fnae and correct to the best af my Imowledge, aaid itaat I <br /> am requesting or I am autfiorrzed by the ovmer of the above prelnises to requ�t inspecfion for the operaiion of�pciult Fasni�y <br /> Hame at this location. I agree tio hold harmless the jurisdidion conducang such �^�^�tions, at my request, as to ae�s daim <br /> (indudin9 oosis, exper�ses, and attomeys'fces inaured in ffie irnesbga&ion af sa.xt, _:�m), wtich may be made byr any pelson, <br /> ind�ng the �dersigned, and fi1ed agair�st the jurisdiction, but only where sucr c�airr: �;� q�t of the r�anoe of tfie <br /> jur�diction, induding �Ts �nPioyees, the acaaacy of tl�e information su�;�iN� t� 'L?�s jur�on�.�� part of <br /> this applicabon. <br /> rwn�Em-r� ��2 S�i4�� ��w i�..�;;� n,a,-E P�- (� 0`� <br /> c-1 P PERTY UWNER QAPPLJCANT Q IICENSEE <br /> Effective:2013 July 01 <br /> Updated:20131une <br /> � y �� � <br /> t,�� <br /> ,� <br />