09-105005' M City of Federal Way
Community Development Services
P.O. Box 9718
Federal Way, WA 98063-9718
Ph: (253) 835-2607 Fax: (253) 835-2609
Project Name: ELDER'S HEAVEN AFH
Project Address: 3921 S 337TH ST
4Building - Single lVamily
Permit #: 09 -105005 -00 -SF
Inspection Request Line: (253) 835-3050
Project Description: Home occupation inspection for an adult family home.
Parcel Number: 618143 0260
Owner
Applicant
Contractor
Lender
JEANETTE VANCE
ABDUL KABLOUT
35032 41ST PL S
3008 BENSON RD S
AUBURN WA 98001
RENTON WA 98055
Census Category: 434 - Residential altladd - no change in number of units
Includes: # 1 #2 #3 #4
Occupancy Class:
Construction Type:
Occupancy Load:
Floor Areas . ft. ,0 1 0 0 1 0
Addition 11 Pel"mlt_Inf+ ro-kation,
New
Mechanical Additional
al to Inc Feet - 3rd Floor.................... e b-
Sq. ,0 l�ew /Additional Sq, Feet -Bas iietit.:................ .
Included? ...................................No Plumbing,to,beIncluded? .......... ..... ... ..:.,. ,No
t+M 1=�ures Asst iafed 1A1lth This Kermit 11
CONDITIONS:
Subject to field inspection without plans.
PERMIT EXPIRES Monday, June 21, 2010
Permit Issued on Wednesday, December 23, 2009
I hereby certify that the above information is correct and that the construction on the above described property and
the occupancy and th use will be in accordance with the laws, rules and regulations of the State of Washington
and the City of Federal Way. /'"
Owner or agent: Date:
Ff NALIk'D �,h4pl
City of Federal Way 0
Certificate of Occupancy
This Certificate issued pursuant to the requirements of Section 110.2 of the International Building Code certifying that
at the time of issuance, this structure was in compliance with the various ordinances of the City regulating building
construction or use. This certificate is valid ONLY when endorsed by City staff.
Tenant Name: ELDER'S HEAVEN AFH
Address: 3921 S 337TH ST
Permit #: 09 -105005 -00 -SF
Includes: #1 #2 #3 #4
Occupancy Class:
Construction Type:
Occupancy Load:
Floor Area (sq. ft.) 0 0 0 0
Owner Name: JEANETTE VANCE
JEANETTE VANCE
Owner Name:
Owner Address: 35032 41 ST PL S
AUBURN WA 98001
`' 2— Zy gn 2_
Date
The priority focus in the review and inspection made by the City prior to issuance of this Certificate was on those matters which
experience has shown most seventy affect the health and safety of the general public. Although the City has made as complete a
review and inspection as is reasonably possible (within budgetary time and personnel limitations), the City neither guarantees nor
warrants to the owner /occupant or to any other person that this Certificate evidences strict compliance with each and every
ordinance or regulation of the City or the State of Washington affecting the construction or use of said structure or the land upon
which itis situated. Such compliance is the responsibility of the owner and / or occupant of the, premises.
r
APPLICATION. AND INSPECTION CHECKLIST - Adult Family Marne
Code References: 2006 IRC section R325 (WAC 51-51)
APPLacA7ION NUMBER: t✓ J ` � �` `�
siTE ADDRESS: 7-1 Y Cs) ci .5'4 IN `N I1ASSESSOR'S TAX/PARCEL*: _ _ _ _ - _ _
2 C'� DAYTIME PHONE:
PROPERTY OWNER NAME: c c- Z -2-Z" ( T c'
LICENSEE NAME -(7 DifaoM: ��ws C ` � DAYTIME PHONE:
1 ;4 T+ t r
APPLICANT MUST DRAW A COMPLETE FLOOR PLAN ON THIS, FORM. PLEASE INCLUDE ALL SLEEPING ROOMS (13EDR00MS).
**t1At7if c nDAtAnMt_' Tun trsrrr fTAtt_,TR1anvr"rAV rAt ter T`4(Fm,xiourTw.wi4Trt4 urv,)m Tc c4;:;;DTR4(_ onnM �*l i 1 a. 9; ANN A Alun
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 operallon of an Adult Family Home at this location. I further certify that I
have made 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 licenses) 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 attorneys' fees Incurred In the investigation of such claim),
which may be made by any person, Including the undersigned, and flied against the jurisdiction, but only where such claim arises out of the reliance of
the jurisdiction, Including Its
tt��officers and emp oye%es, the aecuraoy of the Information supplied to the jurisdiction as a part of this application.
NAMEJTTTLE: A L'Cit. t DATE: f .
❑ PROPERTY OWNER ,� APPLICANT ❑ LICENSEE
811109
USE THIS SPACE IF YOU NEED MORE ROOM TO DRAW A COMPLETE FLOOR PLAN