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Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST <br /> Code References:2015 IRC Sectipn 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: <br /> 72 / 9L6• Ve <br /> i <br /> ASSESSOR'S TAX/PARCEL/4:110)53 <br /> SECTION 2—APPLICANT INFORMATION <br /> PROPERTY OWNER NAME: PP 111 G` \ (;`viet _ DAYTIME PHONE: 12S- 3C.4,2 7f <br /> AFH LICENSEE NAME(IF DIFFERENT): � ' t `LV DAYTIME PHONE: 2 "-IA/2( <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 # accuracy of theeiinfor/mation suppli to the jurisdiction as a parte of this ap lication. <br /> NAME/TITLE: .(,G2.-e f t.! C� +�1/ -e b tlit!L l� t �a��<� 'DATE: /'1/ <br /> // <br /> ['PROPERTY OWNER APPLICANT D LICENSEE <br /> (Effective July 1, 2013.) <br /> Effective:2013 July 01 <br /> Updated:2017 February <br />