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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: 7 v 1 1(41.h1 ✓� �"' �/'�'ti/ t l n® ASSESSORS TAX/PARCEL!0.5 ( a° <br /> SECTION 2-APPLICANT INFORMATION <br /> PROPERTY OWNER NAME: £0 P k' DAYTIME PHONE: <br /> AFH LICENSEE NAME(IF DIFFERENT): ' ( -v 4. -f a*, DAYTIME PHONE: 6190 r6/ / 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 <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. J <br /> NAME/TITLE: (��f°►'ie/fkr1 /V " 144 t4c DATE: /b/ 2_y/e <br /> DPROPERTY OWNER LYAPPLICANT Q LICENSEE <br /> Effective:2013 July 01 <br /> Updated: 2013 June <br />