09-104109 r . • Øg10 sw .s pL-
Nil. 2 __-7 DEPARTMENT OF COMMUNITY DEVELOPMENT SERVICES
33325 8th Avenue South
CITY OF t` F ECLT"E PO Box 9718
R R v Federal Way WA 98063-9718
Federal 1A/ay 253-835-2607;Fax 253-835-2609
OCT 2 0 2009 www.cityoffederalway.com
CITY OF FEDERAL WAY
IN-HO11Ic CHILD CARE
LAND USE APPROVAL PPLICATION
�i / / / 0 % / A lication Fee: $48.50
gri(o•
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Name of Child Care: A . & .
Name of Applicant: `<-.6‘7\- f. 1 IOP/1'1"a U' I A(-v�
Address of Child Care: 1--W I b S GJ `?o`LS� P is CC..—.(.._ ,-2,_/ t,..) , 62473
Mailing Address(if ‘
S pr�^
Phone Number: -I2.s-2 t '-ig,Siapening Date of Child Care: c) ► \ DGi
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PLEASE PROVIDE THE FOLLOWING: / r / f
❑Name of family member who resides on-site&operates child care: Sr�n�-� 'V DC�/j� V` l 1a(��-
0 Copy of license from the Dept of Social&Health Services: 0 Enclosed
o-A sketch of your lot that shows your home in relationship to your lot lines. Show where any off-street
parking is provided as well as loading and unloading area(see example on page 4).
0 How many people living outside your home will be working at the child care:
O”Completed&signed Neighbor Notifications(enclosed)for each neighbor adjacent to your home,or provide
the city with stamped, addressed envelopes of the neighbors' addresses and the city will notify them. Note,
please do not submit metered envelopes.The Federal Way Post Office may refuse such envelopes.
Bulletin#029—January 1,2009 Page 1 of 4 k:\Handouts\ln-Home Child Care Application
411 }
❑ Hours and days of operation: \ Cc:. bog,. - l.(2 : U1.)(' soil- -Svn G'.coAvrs G' f•r�
❑Maximum number of children you will take care of on any given day: I p-
❑Number of children residing in the home: 3
❑ Number of vehicles you anticipate coming to your home per day as a result of the child care (include
employees, customers, deliveries, etc.): f 2-.tYi 6y- Please explain:
6A () vp cc-- *tote' i/e a-
�� U--s et L/ <7 L P6 ( --/2a (.t144-2)
❑ Describe any fencing&other buffering devices around the play area(height&materialsT
6 6/0,4- t,),),,4at 40
The International Building Code(IBC)has special requirements for in-home child care centers.Please
provide the following information:
1. What type of house is it? 0 One story 0 Two story 0 Tri level 'Split-level ❑w/Basement
0 Other:
2. A smoke detector shall be provided in all sleeping/napping areas and on each level of the home.Has a
smoke detector affidavit(enclosed)been completed? 12-res 0 No
3. Does the home have an automatic fire suppression system(sprinklers): 0 Yes E''No
4. Each floor level used for child care purposes shall be served bby two remote exi Child carpwild Ibe
located: 0 Basement 0 First story 0 Second story 0 Level: / Lb 6 4 pen teB)
5. If in the basement,is there an exit at ground level(no steps,porches,or decks outside the door):
❑ Yes 0 No O'Not Applicable
6. If in the basement, is there an exit at ground level and a self-closing door at the top or bottom of the
interior stairway(steps,porches or decks outside the door OK): 0 Yes 0 No -Mot Applicable
7. If in the basement,is there an emerge cy escape window or door which leads to a public way:
❑ Yes 0 No DNot Applicable
8. If on the second-story, is there an�ex�irectly to the exterior of the home that does not go through the
first-story: 0 Yes 0 No C�'Not Applicable
9. If on the second-story, is there an exit directly to the exterior of the home and a self-closing door at the
top or bottom of the interior stairway: 0 Yes 0 No of Applicable
Bulletin#029—January 1,2009 Page 2 of 4 k:\Handouts\ln-Home Child Care Application
• •
10. Do the sleeping or napping rooms have at least one operable emergency escape or rescue window(5.7
min sq. ft.,20 inch min. width,24 min.height, and 44 inch max. sill height): E 0 No
11. Do the sleeping or napping rooms have a door directly to the exterior of the building: ErYCs a-N
ore co-?S ; d,L does /o
12. Do any commer - uses.oc •next to the child care area:
�� •► mono If Yes, type of business use:
13. If you answered yes to question#12, is there a fire-resistive separation between the rooms or spaces?
❑ Yes 0 No A'-Not Applicable If Yes,what is rating?
14. If you answered yes to question#13, are there rated and labeled doors or windows in the wall:
❑ Yes 0 No 0 Not Applicable If Yes,what is rating?
15. Building Division Comments:
A BUSINESS SIGN OR OUTSIDE ALTERATIONS TO YOUR RESIDENCE ARE NOT PERMITTED.
I have read and understood that failure to comply with Federal Way City Code, Chapter 22,Article XIII,
Division 6, Section 22-1069,"Home Occupations Class II," is grounds for immediate revocation of the in-
home child care approval. I agree that my child care will be conducted in such a manner that none of these
criteria will be violated and that I will report any changes in the conduct of the above described child care
(including increases in clients) to the Federal Way Department of Community Development Services and
receive approval before the changes take place.
A/‘?i'r' ; �' / `4 (11/'`"-
Full
1•o..-Full Painted Name
C��6
Signa e Date
Planning Representative Date
Building Division Representative Date
Bulletin#029—January 1,2009 Page 3 of 4 k:\Handouts\In-Home Child Care Application
•
SITE PLAN EXAMPLE
Include the following on the site plan:
1) Lot boundaries and dimensions
2) Dimensions between property lines and the house
3) Any areas used for parking, loading,and unloading
4) Adjacent streets
5) North arrow
35 '
PL
Y
C
20PL = Property Line
� � a
8 '
House
Garage
N
[Driveway
30 '
Car 3 Gr 4
PL--
70 '
L 70 '
1st Street
Bulletin#029—January 1,2009 Page 4 of 4 k:\Handouts\In-Home Child Care Application
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• •
NIL DEPARTMENT OF COMMUNITY DEVELOPMENT SERVICES
CITY OF 33325 8th Avenue South
PO Box 9718
Federal \1Iay
9
Federal Way WA 98063-9718
253-835-2607;Fax 253-835-2609
www.citvoffederalw-ay.com
SMOKE DETECTOR AFFIDAVIT
IN-HOME CHILD CARE
Date: P3 1 v"(
Print Owner's Name: d M eJ Igt No: 01—( (O cl
Print Street Address: ,- r( D S k) �'�--
Print City, State, Zip: bcF\- 7
I hereby certify, under perjury, that a properly operating smoke detector has been installed in the
dwelling unit within the building for which this application is being made.
Owner's Signature:
Bulletin#031 —January 1,2006 Page 1 of 1 k:\Handouts\Smoke Detector Affidavit
•
•
AIL DEPArrMIIrr of CossmuNrry DEvELorstErrr SEIvicFS
33325 8th Avenue South
CITY OF 1111111 PO Box 9718
yFederal 253-835-7f507,Fax 251-835-7409
www.cityot3•ederalway.caun
_ NOTIFICATION
L5 CI A l� i G/h em ki \ Gt( v'►�— is proposing an in-
(Applicant's Name)
home child care at `! &�i 5 ki (Phi Ex. . As pat of the
(Address) P•rd
Federal Way in-home child care application process,notification of a;jacut neig,hbors
Each adjacent neighbor should read and sign this form. (Applicant. please make as many
copies as necessary.) This child care will have a maximum of i `"` children at any one
rime, including ' children already residing on the premises.
Please call the Fedw t Way Department of Com • ity Development Services t 253-835-2607
if you have any question or concerns.
Vf VVla4.r1
Are yvu the pro- uwuu: / i Guaut: _ r zinc aag,t1 yvui Ild.111G a3 eu zwulvwicurviuGUL
of uvuu atiou.
CYI - GG2 � C 4 4 r /O
!Cion Name) (Print Name) Mato.)
4-A2o
(Street Aririrrcc)
C` k)/1 9erUZ3
(City state 7in)
Return to the Department of Community Development Services at the above address.
Bulletin#30—January 1.2007 Pace I of I k\Handouts\Neiehbor Notification
• 11111
1466 DEPARTMENT OF COMMUNITY DEVELOPMENT SERVICES
33325 8th Avenue South
CITY OF 111111 PO Box 9718
Federal WayFederal Way WA 98063-9718
253-835-2607;Fax 253-835-2609
www.cityoffederalway.com
NEIGHBOR NOTIFICATION
NEIGHBOR
IN-HOME CHILD CA°_F
\\ :A( v._ is proposing an in-
(Applicant's Name)
home child care at `7 / C 5 w P/11 lsL . As part of the
(Address) - c?Ae,cia GvcuJ „L,i 1S0
Federal Way in-home child care application process, notification of adjacent neighbors is required.
Eaca acijaceni neighbor should read and sign this form. (Applicant, please make as many
copies as necessary.)This child care will have a maximum of children at any one
time, including :> children already residing on the premises.
Please call the Federal Way Department of Community Development Services at 253-835-2607
if you have any question or concerns.
Are you the property owner? Tenant? _ Please sign your name as an acknowledgement
of ratification.
1,
M& 4//41
Vii/g P- /P/19
( ti /
I;
(Sign �) ! tr -. (D �)
F (StreetD
(City,State,Zip)
Return to the Department of Community Development Services at the above address.
Bulletin#30—January 1,2007 Page 1 of 1 k:\1-Iandouts\Neighbor Notification
(For office use only)
I FWBL#2.9 /v 674) -BL I
•
, BUSINESS LICENSE APPLICATION
Please type or print clearly in dark ink.
ENApplication ❑Update Application/Address Change
ed_eral Way Business UOutside Contractor UHome Occupation UOther
SECTION A - Business Information - Please complete all information.
Business Name rin 6 49G1(n,:4)WA State UBI #(1-800-647-7706)
Business A (Street/Site! o,I&` Ark# carte." C*'it-1-e Co
d ess uy al ca
otion) Are you currentlyyi D . /�
l 6 J ($2-- Ph )t ttoccupying
this address.DYes ❑No
t
City
StatA_ Zipo 0.
3 Airls_3PJ `7'"• i3,
Mailing A dress 1 City State Zip usiness Fax :
Is this a Non-Profit Organization established for educational, Number of persons employed in Federal Way:
religious,or charitable purposes? Oyes � # f Full Time It Part Time
Is there Liquor served on the premise? DYes o Is there Gambling activities? DYes =CINo
If yes, State Liquor License it If yes, State License#
SECTION B - Description of Business - describe in detail your business activities-including
which category-retail, wholesale, or services.
S±a. ce„S.e L L d UCw� 60c_ &f.; �, .._. y /c ;t
SECTION C - Business Ownership -Attach additional pages if necessary.
GdSole Proprietor ❑Partnership UCorporation ULimited Liability ❑Non-Profit ❑Other
Company Name
(As registered with WA State): o a i 1 /-4 (11.i` Li LUr"r-- (k.nI-PE ril J C4-e-11'�,"--'
Number of Owners, Partners, Date Business began �,
or Corporate Officers: / or will begin in FW: :irk & I i p Cl
Nam Title:
��� \ ' /� �• I Driver License#/State: (,,LJ p- Birthd te:)
� al
Aephf on 0 wr^e r V l 11 C1 it,;4 to Du. 3 Now_
! Home Addresstr et/PO Box, City, State Zip) --- Telephone Number: %Owned:
l0 StJ ?.5'4'E)l 4 c-c— 4-��r�,erW( Goad, /1fA.y) D-(,�- c!s-Q a
Name: Title: r a `�" r a MOD iver License# tate: -L, BI d.te:
a tisim :.—, imcwasmir - .,
Home Address (Street/PO Box, City, State, Zip) Telephone Number %Owned:
Name of Emrgency Notificatio / ontact:„......s_e
Telephone No.:
i s �r ���(Oy\ yLPO —y / CD
SECTION D - Business Location - Some improvements to your business may require separate
permits. Please contact the Community Development permit counter at(253)835-2607 for more information.
King County Parcel #: I Are you making tenant improvements? DYes LINO
c . 3 A( ) 01(
Building: mingle Tenant I Floor Space Usedr, - Name of Business Center(if applicable):
,AMultiTenant for Business(Sq. Ft.): ' 6 60 SI&
Does building/premise have IfY s, monitor by: City alarm registration no.:
a security alarm system? /aces
CI j]f x /--I Arm
SECTION E - Hazardous M ials -Required by the City of Federal Mt and Fire Department.
Does your facility currently report to the Fal Way Fire Department under Sara Title Mir ❑Yes 'No
Does your facility currently use or store flammable materials? ❑Yeso
If yes, please list.
What types of hazardous materials and/or waste are used, stored,handled, processed, or generated by your
business? If additional space is needed, please attach a separate sheet(s) of paper.
iU Or e—
What
What quantity(in gallons) of the above substance is stored on site at any given time? /1/ j
(Excluding consumer commodities for household use packaged in quantities of less than five (5)gallons)
SECTION F — Home Occupation - If you are applying for an Adult Family Home or In-Home
Daycare please contact Community Development Department at 253-835-2607 for additional requirements.
Name all family members who reside at the home and work in the business, include yourself:i�/
0.A*k I/AU°A l d Lf1l�n�dn ZS tL��1.€a1 �Cll✓��IA(I 2-CJe Ui 1 WO/►
Name of Apartment/Townhouse Complex:(If applicably Complete Floor Space of Residence:
2cad78 ,SfyGr4--
W ill there be any outside storage\o(goods, display of materkals or outside activity?,0Ves ❑ o
If Yes, please explain: re-t t' (i,A j n b..(LL -�
Will the b�ush ess require the use of heavy equip ent, ower tools or pow&sources not common to a residence?
❑YesVo, If Yes,please explain:
Will there be any pick up or delivery by commercial vehicles? ClYese-lallo
If Yes, please explain type and frequency:
Will there be any visits to the home by clients, employees, or delivery services? s ❑No
If Yes, please explain the number of deliveries expected: per week l-'i 2. per month "' z7(1
Are there any conditions produced by the home occupation such as noise,vibration,smoke, dust,odor,heat,or glare
which would exceed that normally produc d by a single residence,or which could create a disturbing or objectionable
condition in a neighborhood? ClYes lo If Yes,please explain type and frequency:
SECTION G— Temporary Business Activity - Temporary Licenses are granted for a specific
period, and are not to exceed 90 days in a calendar year.
Description of Temporary Business/Activity:
Specific Dates of Temporary Activity:
Is site layout of area/structures provided? ❑Yes ONo Signed Consent of Property Owner must be attached for
(including ingress and egress of area) approval.Copy of lease agreement is acceptable.
SECTION H — SIGNATURES
I (we) the undersigned, declare under the penalties of perjury and the denial of a license or revocation of any license
granted,that I(we)am(are)the applicant(s)or authorized representative(s)of the firm making this application and that the
answers contained,including any accompanying information have been examined by me(us)and that the information set
forth is true, correct,and complete. I also understand that I am responsible for notifying the City Clerk, in writing, of any
change in location or mailing address within thirty days. All licenses are nontransferable. I understand my place of
busines must comply with all federal,state,and local codes and ordinances.
x Iitit4 Ck') /0 cj 0'7
�}
Signatu of applicant Title Date
u.rb 9W-) z 7
Application prepared by(please print) Title Phone Number
For office use only
Amount Received: 7 5. Check No.: /0 Date Received:_/ 6/ 0.9 Receipt No.:(7.5-)--LI 7q
Business License#: O 101/D qJ SIC CODE: Date/License Issued: