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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References:2012 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: 5' 110 AI y I e'O3 P EV "e 1 ) w A ASSESSOR'S TAx/PARCEL OO 05.g000OOt of <br /> SECTION 2-APPLICANT INFORMATION <br /> PROPERTY OWNER NAME: Y0 kA A Moi tS . De-S4-e•- DAYTIME PHONE:(_206)24-0- 60I <br /> • <br /> AFH LICENSEE NAME(IF DIFFERENT): A ey% N pje-sT Af 4 LL C° DAYTIME PHONE:C O 4 4,6.8- 1419 <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 <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.NAME/TITLE: Q Vi AJ 1€�� td DATE: 7/t /' ' <br /> PROPERTY OWNER ®APPLICANT ®LICENSEE <br /> Effective: 2013 July 01 Of I( <br /> Updated:2013 June <br />