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a <br /> 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: 102-3 I`4'_vi c iO A LU'l-1-0+ ) km A w) ASSESSOR'S TAX/PARCEL#: <br /> SECTION 2—APPLICANT INFORMATION <br /> PROPERTY OWNER NAME: MU l U ()eke, G kSi1U ekv\c Ve...f/14 AREeC DAYTIME PHONE: 22c,G.-3 -29 <br /> AFH LICENSEE NAME (IF DIFFERENT): 1Sk AL3UIUTAIU CE OF Love AFI LLC DAYTIME PHONE: 06,--ft E— 211 <br /> SECTION 3— FLOOR PLAN <br /> On a separate sheet of paper (8 1 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. <br /> NAME/TITLE: �M C f� DATE: 3 \ 1 l l <br /> ROPERTY OWNER CIAPPLICANT D LICENSEE <br /> Effective: 2013 July 01 <br /> Updated: 2013 Ma <br /> )77 <br />