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CA rI-c),S -cO3 <br /> Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References:2015 IRC Section R325(WAC 51-51) <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 /> SITE ADDRESS 12 foga- s¢ SE 40' A -_( i 5 ASSESSOR'S TAX/PARCEL#: <br /> SECTION 2—APPLICANT INFORMATION <br /> PROPERTY OWNER NAME: V/A 2 ,V( NA-MAwlgA 4- POZ(CIA 14(4M° DAYTIME PHONE: Qo C 85 ct <br /> I�IO <br /> AFH LICENSEE NAME(IF DIFFERENT): Y if IA d. d�( -m(Ly Hum DAYTIME PHONE: 2,0 ?sett P r <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 /> 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 the accuracy of the information supplied to the jurisdiction as a part of this application. <br /> NAME/TITLE: I�ite( urN r , MAM i A - DATE: /3//ep <br /> PROPERTY OWNER KrAPPLICANT D LICENSEE <br /> (Effective July 1, 2013.) <br /> Effective:2013 July 01 <br /> Updated:2017 February _ <br />