13-102992f
Applicant
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Gilding - Single Fam'YYy
NORI BALI
City of Federal Way
Community &Econ. Dev. Services
Permit #: 13-102992-00-S F
NORMA BALI
33325 8th Ave S
Federal Way, WA 98003
Ph: (253) 835-2607 Fax: (253) 835-2609
Inspection Request Line: 253 83
p q � � 5-3050
Project Name: PINNACLE ADULT FAMILY HOME
Project Address: 33006 28TH AVE SW Parcel Number: 894520 0880
Project Description: ALT - Verification of Occupancy for Adult Family Home.
***No construction work allowed under this permit.***
Owner
Applicant
Contractor
Lender
NORI BALI
NORMA & NORI BALI
NORMA BALI
31614 12TH PL SW
33006 28TH AVE SW
FEDERAL WAY WA 98023
FEDERAL WAY, WA 98023
Census Category: 434 - Residential alt/add - no change in number of units
Includes: #1 #2 #3 #4
Occupancy Class:
Construction Type:
Occupancy Load:
Floor Areas . ft. 0 0 0 0
Additional Permit Information
New / Additional Sq. Feet - 3rd Floor....................0
Mechanical to be Included?....................................No
New / Additional Sq. Feet - Basement...................0
Plumbing to be Included?.......................................No
No Fixtures Associated With This Permit!!
CONDITIONS:
***No construction work allowed under this permit.***
PERMIT EXPIRES Saturday, January 4, 2014
Permit Issued on Monday, July 8, 2013
I hereby certify that the above information is correct and that the construction on the above described property and
the occupancy and he use will be in accordance with the laws, rules and regulations of the State of Washington
and the Ci of Federal Way.
Owner or agent:- z L L t� Date: 7 J��`�
Adult Family Hom*AFH) LOCAL BUILDING INSPECT CHECKLIST
Code References: 2012 IRC Section R325 (WAC 51-51) I I
FILE APPLICATION NUMBER:
ISP
SECTIONS 1. 2. 3. AND 4 MUST BE COMPLETED BY APPLICANT BEFORE INSPECTION WILL BE PROCESSED
SECTION 1- PROPERTY INFORMATION
SITE ADDRESS: v F Ow( g 17 14 Ile: v ?l" ASSESSOR'S TAX/PARCEL#:
PROPERTY OWNER NAME:
DAYTIME PHONE: dp(, �w-
AFH LICENSEE NAME (IF DIFFERENT): / (o /,-/W o 116A11 ' DAYTIME PHONE: W�4 9��-4�11:v
SECTION 3 - FLOOR PLAN
On a separate sheet of paper (8 1/2x 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.
RECEIVED
a&P �,r
JUL 069 2013
CITY OF FEDERAL WAY
CDS
SECTION 4 - DISCLAIMER/SIGNATURE BLOCK
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 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 annliration.
NAME/TITLE: / P11?X /%7 /541-1 DATE
WROPERTY OWNER ❑APPLICANT ❑ LICENSEE
7/0//--'5
Effective: 2013 July 01
Updated: 2013 June
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RECEIVE[ PERMIT
Federal Way II'' I
COMMUNITY DEVELOPMENT SERVIJU L OS 20'A P P L I C AT I O N
253-835-2607• FAX 253-835-2609
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CITY OF FEDERAL WAY
CDS
MF CO ME PL DE EN FP
r�o', $°l
SITE ADDRESS i
SUITE/UNIT #
PROJECT VALUATION
ZONING �
ASSESSOR'S TAX/PARCEL M i
TYPE OF PERMIT
(BUILDING ❑ PLUMBING ❑ MECHANICAL
❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
(Tcriant Name/Homeounier Last Narne)
PROJECT DESCRIPTION
i
Detailed description of Mork to
be included on this permit only
PROPERTY OWNER
NAME
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PRIMARY PHONE
G (�'S y _ ��� /
MAII.ING �REtR,S/� , n �i-
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PHONE
MAILING ADDRESS
E-MAIL
CONTRACTOR
CITY
STATE
ZIP
FAX
WA STATE CONTRACTOR'S LICENSE •
EXPIRATION DATE
FEDERAL WAY BUSINESS LICENSE k
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—
NAME \ /
PHONE
MAILING ADDRESS �j
E-MAIL
APPLICANT
C
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ZIP Z •.,
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FAX?
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PROJECT CONTACT
NAME
PHONE
(The individual to receive and
MAILING ADDRESS
E-MAIL
respond to all correspondence
concerning this application)
CITY
STATE
ZIP
FAX
ALTERNATE CONTACT NAME:
PHONE
E-MAIL
PROJECT FINANCING
NAME
® OWNER -FINANCED
Required value of $5.000 or more
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
(RCW 19.27.0951
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner. I certify that to the best
of my knowledge, the information submitted in support of this permit application is true and correct. I certify that I will comply with
all applicable City of Federal Way regulations pertaining to the work authorized by the issuance of a permit. I understand that the
issuance of this permit does not remove the owner's responsibility for compliance with local, state, or federal laws regulating
construction or environmental laws.
I further agree to hold harmless the City of Federal Way as to any claim (including costs, expenses, and attorneys' fees incurred in
the investigation and defense of such claim), which may be made by any person, including the undersigned, and filed against the city,
but only where such claim arises out of the reliance of the city, including its officers, and employees, upon the accuracy of the
information supplied to the city as a part of this application.
t
SIGNATURE: DATE
PRINT NAME:
Bulletin #100 — April 14, 2010 Page I of 3 k_ Handouts\Permit Application