Wac 51-51-0325 - Adult Family Home (Afh) Local Building Inspection Checklist printable pdf download

Wac 51-51-0325 - Adult Family Home (Afh) Local Building Inspection Checklist

Adult Family Home (AFH) LOCAL BUILDING INSPECTION CHECKLIST

Code References: 2012 IRC Section R325 (WAC 51-51)

:_____________________

PPLICATION

UMBER

1, 2, 3,

ECTIONS

AND

MUST BE COMPLETED BY

PPLICANT BEFORE INSPECTION WILL BE PROCESSED

SECTION 1 – PROPERTY INFORMATION

SECTION 1 - PROPERTY INFORMATION

SITE ADDRESS: ______________________________________________________________________________ ASSESSOR’S TAX/PARCEL#:_ _ _ _ _ _ _ - _ _ _ _

SECTION 2 - APPLICANT INFORMATION

SECTION 2 – APPLICANT INFORMATION

PROPERTY OWNER NAME: ___________________________________________________________

DAYTIME PHONE: ____________________

AFH LICENSEE NAME

DAYTIME PHONE: ____________________

(IF DIFFERENT): ________________________________________________________________________

SECTION 3 – FLOOR PLAN

On a separate sheet of paper (8 ½ 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 components for exiting i.e., stairs, ramps, platforms, lifts and

elevators.

SECTION 4 – DISCLAIMER/SIGNATURE BLOCK

I certif y under penalty of perjury that the inf ormation 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 costs, 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

jurisdiction, including its officers and employees, upon the accuracy of the information supplied to the jurisdiction as a part of

this application.

NAME/TITLE: _________________________________________________________________________ DATE: __________________________

PROPERTY OWNER

APPLICANT

LICENSEE

Effective: 2013 July 01

Updated: 2013 May

Wac 51-51-0325 - Adult Family Home (Afh) Local Building Inspection Checklist