1832GOVERNMENT GAZETTE, WA 23 March 2017

1832 GOVERNMENT GAZETTE, WA 23 March 2017 Rooms for private use Number Area Laundries/toilets/bathrooms ……………….. ……………….. Bedrooms ……………….. ……………….. Dining Rooms ……………….. ……………….. Kitchens ……………….. ……………….. Sitting Rooms ……………….. ……………….. Other (Specify) ……………….. ……………….. Rooms for lodgers Number Area Bedroom ……………….. ……………….. Dining Rooms ……………….. ……………….. Kitchens ……………….. ……………….. Sitting Rooms ……………….. ……………….. Other (Specify) ……………….. ……………….. Sanitary Conveniences for male lodgers Toilets ……………….. Urinals ……………….. Baths ……………….. Showers ……………….. Hand wash basins ……………….. Sanitary Conveniences for female lodgers Toilets ……………….. Baths ……………….. Showers ……………..… Hand wash basins ……………….. Laundry Facilities Wash troughs ……………….. Washing machines ……………….. Drying cabinets or clothes lines ……………….. Additional Details (a) Lodgers’ meals will be provided by the manager/keeper/lodgers. (b) The keeper will/will not reside continuously on the premises. (c) Name and occupation of proposed manager if keeper resides elsewhere— .......................................................................................................................................................... (d) There will be......................family members residing on the premises with the keeper/manager. Application fee of $......................... is attached. ......................................................................................... ....................................................... (Signature of Applicant/s) (Date) ————