10-104430A
4 Is DEPARTMAF COMMUNITY DEVELOPMENT SERVICES
33325 8`h Avenue South
PO Box 9718
CITY OP � Federal Way WA 98063-9718
(�(� 253-835-2607; Fax 253-835-2609
Federal Way File #: "" V qV E 2ffederalway.com
OCT
IN HOME FAMILY DAY CARkITy OF FEDERAL wAy
LAND USE REVIEW CDs
Name of Day Care:
Address of Day Car
Name of Applicant:
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Mailing Address (fdierent): c�
Phone Number:E-Mail: Y 1 &yy)QtLo (t5'7V
Name of family member who resides onsite & operates day care: I �►�
Number of people living outside your homethat will be working at theday care: t y IPT
Family day care is for ❑ Adults ) Children ❑ Both
Hours and days of operation: b n Y Y l —
Maximum number ofchildren/adultsyou will care for on any given day.
(including those requiring care who reside in the homo
Attach site plan showing:
Property Boundaries and Dimensions North Arrow
Adjacent Street Names Location of Off -Street Parking and Loading Areas
Location of Structures on Site Distance from Structures to Property Lines
Attach Neighbor Notification forms, completed and signed, for each property adjacent to the proposed
family day care or submit stamped, addressed envelopes for each property with this application and they
will be notified by thecity.
APPROVED BY:
(Reviewer) (Date)
Bulletin #029 —January 1, 2010 Page l of 2
k:\Handouts\Family Day Care Application
QED •
W • (For office use only)
r O FWBL # 20- � - -BL
OCT 19 .3(3
CITY OF FEDERAL \RWINESS LICENSE APPLICATION
JR�Application UUpdate Application/Address Change
Federal Way Business OOutside Contractor )XHome Occupation OOther
CCf`Tif'IKI A — Rrscinncc Infn..k nfinn - Pfnnca r-mmnlata all infnrmatinn
Busin ss NameY
WA State UBI # (1-800-647-7706)
As registered with WA State): i k1A IrA VP2
Business Add s (Street/Suite Physical Location) Are you currently occupying this address?OYes ❑No
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Number of Owners, Partners,
Y%
State
Zip
Business Phone #:
or will begin in FW:
2-3
-
Mailing Address 1
City
State
Zip
Busine s Fax #:
3
0 1 _ 5—H 4PJ5
a Address (Street/P0 Box, Ci , State, Zi)
Telephone
Number:
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Is this a Non -Profit Organization established for educational,
Number of persons employed in Federal Way:
religious, or charitable purposes? ❑Yes ❑No
# Full Time # Part Time
Is there Liquor served on the premise? ❑Yes ❑No
Is there Gambling activities? ❑Yes ❑No
If yes, State Liquor License #
If yes, State License #
SECTION B — Description of Business — describe in detail your business activities -including
Mich category - retail, wholesale, or services.
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SECTION C — Business Ownership -Attach additional pages if necessary.
MC -1- D— A -f -r MD—f--hi n r11- nrnfinn Fit imitarl 1 inhilihr rlhlnn-Profit ❑nthPr
Company Name
V
As registered with WA State): i k1A IrA VP2
I K) I PW6
Number of Owners, Partners,
Y%
Date Business began
Awl
or Corporate Officers: T
or will begin in FW:
N me:
Title:
Driver License#/State:
Birthdate:
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0 1 _ 5—H 4PJ5
a Address (Street/P0 Box, Ci , State, Zi)
Telephone
Number:
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% Owned:
9TH ti
Name:Title:
D er License#/State:
Birthdate:
AWO r�uol �Nn
Home Address (Str t/PO Box, City, State, ip)
Telephone Number:
% Owned:
I u kZ tv141
Name of Emergency Notification/Contact:
Telephone o.:
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SECTION D — Business Location - Some improvements to your business may require separate
ermits. Please contact the Community Development permit counter at (253) 7335-Zeui for more inrormatlon.
King County Parcel #.31 Q g Are you making tenant improvements? (3Yes ❑No
l ()
Building: ❑Single Tenant Floor Space Used 3 l S Name of Business Center (if applicable):
ulUTenant for Business (Sq. Ft,):
Does building/premise have If Yes, monitored by: Ilk City alarm re istration no.:
a security alarms stem? Oyes *o
J
SECTION E - Hazardous Materials - Required by the Citv of Federal Wav and Fire Deoartment.
Does your facility currently report to the Federal Way Fire Department under Sara Title 111? ❑Yes MNo
Does your facility currently use or store flammable materials? QYes )OLNo
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.
What quantity (in gallons) of the above substance is stored on site at any given time?
(Excluding consumer commodities for household use packaged in quantities of less than five (5) gallons)
SECTION F— Home Occupation - ffyou are applying foran Adult Family Home orin-Home
Davcare please contact Communitv Develonment Denartment at 253-835-2607 for additional reauirements.
Na�mlea II family members woo reside at th home and work in the business, include nurse f:
J
�� Y
Name of artm t/T wnhouse Complex:(If applicable)
Complete Floor Space of a dence:
Will there/be any outside storage of goods, display of materials or outside activity? DYes EINo
If Yes, please explain:
Will the business require the use of heavy equipment, power tools or power sources not common to a residence?
❑Yes Wo, If Yes, please explain:
Will there be any pick up or delivery by comme tial vehicles? es ❑No
If Yes, please explain type and frequency: Y QYMC
Will there be any visits to the home by clients, employees, or delivery services? XYes ❑No
If Yes, please explain the number of deliveries expected: per week per month
Are there any conditions produced by the home occupation such as noise, vibration, smoke, dust, odor, heat, or glare
which would exceed that normally produced by a single residence, or which could create a disturbing or objectionable
condition in a neighborhood? ❑Yes *o If Yes, please explain type and frequency:
SECTION G— Temporary Business Activity - Temporary Licenses are granted for a specific
eriod, 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? - DYes ❑No Signed Consent of Property Owner must be attached for
(including ingress and egress of area) I 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 1 (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 1 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
business must comply with all federal, state, and local codes and ordinances.
of applicant
Title
Ld
Date
her 4 bbl --R1Z;-
Application prepared by (please print) Title Phone Number
For office use only
Amount Received: Check No.: Date Received: Receipt No.:
Business License #: SIC CODE: Date License Issued:
41
RECEIVED
0 C T 19 DEPARTMENT OF COMMUNITY DEVELOPMENT SERVICES
(" 33325 8h Avenue South
CITY OF Vz�:PO Box 9718
ITY OF FEDERAL WAY Federal Way WA 98063-9718
Federal Way253-835-2607; Fax 253-835-2609
.� www.citvoffederalway.com
NEIGHBOR NOTIFICATION
FAMILY DAY CARE
A Family Day Care has been proposed at the following address:
M
A family day care is a business conducted by the occupant of a private residence providing
care for up to 12 children or adults during part of a 24-hour day. Family day cares are
allowed in conjunction with an established residential use in any zoning district in the City of
Federal Way. In addition to state licensing requirements, the Federal Way Revised Code
(FWRC) has restrictions and requirements for family day cares. The complete code can be
viewed through the City's web page www.cityoffederalway.com (FWRC 19.105.070).
Because your residence abuts this property, you are being notified as required by the FWRC.
This facility will have a maximum of clients at any one time (in addition to any
family members requiring care).
Please sign below as an acknowledgement of notification.
If you have any question or concerns feel free to contact the Department of Community
Development Services at 253-835-2607.
0/to 19 --
(Signa e) (Street Address)
,�RtsTi J6 Revs V 1J
(Print Name)
Bulletin #030 —January 1, 2010 Page l of l
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(Date)
k:\Handouts\Neighbor Notification
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Applicant's name
Address
HOME FLOOR PLAN SKETCH
*� - 104u3a
CEIVED
OCTJ92010
Instructions: Sketch a basic floor plan of your home. If—yot4i619.KA%swAy
more than one level, include a floor plan of each level thatCl be
used for child care activities.
Then identify {x} mark the following items on the sketch:
{x} Location of doors and windows that eft to the outside
{x} Location of doors between rooms
{x} Location of each smoke detector and each fire extinguisher
{x} Length and width measurements or squ.fie footage of the usable
floor space in each room used for child care activities
{x} Relative location or a written description of the outdoor place
where all persons will meet during fire drills
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