REVIEWED AFH ChecklistAdult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST
Code References: 2015 IRC Section R325 (WAC 5151)
APPLICATION NUMBER:
SECTIONS 1. 2. 3, AND 4 MUST BE COMPLETED By APPLICANT BEFORE INSPECTION HALL BE PROCESSED
SECTION•• • •
PROPERTY OWNERNAME: IS till Rk Le-U o GZj G (�.."AYTIME PHONE: IU)b 711 b 11 I
AFH LICENSEE NAME (IFD1 :MGhbDW bAL,c. RENCI' A- -H DAYTIME PHONE: 20(0 2IkSZLlI
On a separate sheet of paper (81/2 x 11) draw a floor plan (including all
floors) of your prospective AFH. Include all sleeping rooms (bedrooms)
indicating which bedroom is: A, B, C D, E and F.
Label all componentsfor exiting i.e., stairs, ramps, platforms, lifts and
elevators.
SECTION• BLOCK
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 premises to request Inspection for the operation of an Adult Family Home
at this location. I agree to hold harmless the jurisdiction conducting such inspections, at my request, as to any claim (including cost,
expenses, and attorneys' 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 reliance of the jurisdcton, Including its officers and
employees, upon the accuracy of the information supplied to thejurisdiction as a part of this application. ^
NAMEITITLE:� A-" P, IS Q,U nQQ —e-ram DATE: %16b � I � S 1A
PROPERTY OWNER ®APPLICANT QLICENSEE
(Effective July 1, 2013.)
Effective: 2013 July Ol
Updated: 2017 February
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