111025001040_0001.pdfAdult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST
Code References: 2009 IRC section 8325 (WAC 51-5I)
APPLICATION NUMBER:
SECTIONS fn AND ftfaT MECO PLETED SY APPLICANT BEFOREINSPECTION WILL BE PROCESSED
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PROPERTY OWNER NAME: DAYTIME PHONE:
AFH LICENSEE NAME (IF DIFFERENT): AVGLUT F-A*it 1 W AhfO-If' CAle,- DAYTIME PHONE'
sEcTioN, 3 — FLOOR PLAN
APPLICANT MUST DRAW COMPLETE FLOOR PLAN/S ON THIS FORM (ALL FLOORS). PLEASE INCLUDE ALL SLEEPING ROOMS (BEDROOMS).
ON THIS DRAWING, INDICATE WHICH gpgoom ISA B . D, E. AND F. LABEL ALL COMPONENTS FOR EXITING i.e., STAIRS.
RAMPS: PLATFORM LIFTS & ELEVATORS.
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LIN 4 — DISCLAIMER /SIGNATURE BLC
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 requesting or I
am authorized by the owner of the above promises to request inspection for the operation of ari Adult Family Home at this location. I agree to hold
harmless the jurtsdiction conducting such Inspections, at my request, as to any claim (ftlud4ng costs, expenses, and attomeys'fees Incurred in the
investigation of such claim), which may be made by any person, including the undersigned, and filed against the jurisdiction, but only where such
claim arises out of the reflarce at the jurisdiction, including its officers and employees, upon the accuracy of the information supplied to the
jWiSdIction as a part of this application. 7
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.13, PROPERTY OWNER E] ApPLI&NT LICENSEE-,