Laserfiche WebLink
Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References:2015 IRC Section R325(WAC 51-51) /1 <br /> APPLICATION NUMBER: C I1 t?j'oo <br /> SECTIONS 1. 2. 3. AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED <br /> SECTION 1- PROPERTY INFORMATION <br /> SITE ADDRESS: b C RS' C-K-e" Le/L.. Au-e VIJict cleeli3SSESSOR'STAX/PARCEL#: X01-9$700 Of 00400 <br /> SECTION 2-APPLICANT INFORMATION <br /> 0-1-Alfg -4'A s u N or?'9 0 ` <br /> PROPERTYOWNERNAME: O (S'OL-f{r tocCINfOui DAYTIME PHONE: at -s7( ZFi� <br /> Re* 303 0.6 1-cit <br /> AFH LICENSEE NAME(IF DIFFERENT): DAYTIME PHONE: <br /> SECTION 3- FLOOR PLAN <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 /> FILE COPY <br /> SECTION 4- DISCLAIMER/SIGNATURE 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 am <br /> requesting or I am authorized by the owner of the above premises to request inspection for the operation of an Adult Family Home <br /> at this location. I agree to hold harmless the jurisdiction conducting such inspections, at my request, as to any claim (including costs, <br /> expenses, and attorneys' fees incurred in the investigation of such claim), which may be made by any person,including the undersigned, <br /> and filed against the jurisdiction, but only where such claim arises out of the reliance of the jurisdiction, including its officers and <br /> employees, upon theaccuracy of the information supplied to the jurisdiction as a part of this application. � <br /> NAME/TITLE: N �q1 <br /> Q�(StSL�3 h,O S yN fY1 U DATE: " — o <br /> ['PROPERTY OWNER �PPLICANT O LICENSEE <br /> (Effective July 1, 2013.) <br /> Effective:2013 July 01 <br /> Updated:2017 February <br />