2008, 06-23 Permit App: 08002372 Adult Family Home InspectAPPLICATION AND INSPECTION CHECKLIST - Adult Family Home
Code References: 2003 IBC 310 (WAC 51-50) and 2003 IRC 110 (WAC 51-51)
APPLICATION NUMBER: a3
Applicant must complete sections 1, 2, 3, and 4. Application must be complete to be processed.
"SECTION 1 jPROPERTY;INFORMATIONw;,�?,
SITE ADDRESS: 1/ 7/ / £ , .L &KORA ' cbR
ASSESSOR'S TAX/PARCEL #:
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PROPERTY OWNER NAME: 1 .6AbviS A, Mo u -
LICENSEE NAME (IF DIFFERENT)
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'SECTION`3 ` FLOOR 'PLAN `tE
DAYTIME PHONE: 5C9 79'7-777`!
DAYTIME PHONE: 24 ./ 47-7175-n9"65g- f;
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A complete floor plan must indude all sleeping rooms, identified by number (#1, #2, #3 etc) and all components for
exiting, i.e. stairs, ramps, platform lifts and elevators. (Attach additional sheets if necessary)
SECTION'4.4 DISCLAIMER/SIGNATUREBLOCK
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 further
certify that I am in the process of making an application to the Department of Social and Health Services for an adult family home license and that I
have also made application to the applicable jurisdiction for the appropriate license(s) to conduct such business at this location. I further agree to
hold harmless the jurisdiction conducting such inspections, at my request, as to any claim (including costs, expenses, and attomeys' fees incurred in
the investigation of such claim), whidi may be made by any person, induding the undersigned, and filed against the jurisdiction, but only where
such claim arises out of the reliance of the jurisdiction, induding its officers and employees, upon the accuracy of the information supplied to the
jurisdiction as a part
/ooJf this application.
NAME/TITLE: C C'22/Oil
D PROPERTY OWNER 0 APPLICANT 0 LICENSEE
DATE: O‘, -.2 3-0-�
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