Laserfiche WebLink
Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References:2015 IRC Section R325(WAC 51-51) <br /> p,s 8 ��� APPLICATION NUMBER: <br /> dl-fi� <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: gl `14+1S+ SE G U 'eA <br /> g4 2-0 C? ASSESSOR'S TAX/PAR CEL#: - <br /> SECTION 2-APPLICANT INFORMATION <br /> berhPROPERTY OWNER NAME: a�Q S 1-e. DAYTIME PHONE:�p 3s 4t- 0`T S <br /> AFH LICENSEE NAME(IF DIFFERENT): Pro Art eten odoa owe DAYTIME PHONE:°2p&'-354- `o9S <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 (- Pe-5- <br /> of the information supplied to the jurisdiction as a part of this application. <br /> NAME/TITLE: t ho1V' e-5-�`-e DATE: ZZ�� <br /> DPROPERTY OWNER ®APPLICANT 0 LICENSEE <br /> (Effective July 1, 2013.) <br /> Effective:2013 July 01 <br /> Updated:2017 February <br /> (..// <br />