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Home My WebLink AboutPermit D08-523 - LABEL RESIDENCE - ADDITIONThis record contains information which is exempt from public disclosure pursuant to the Washington State Public Records Act, Chapter 42.56 RCW as identified on the Digital Records Exemption Log shown below. D08 -523 Label Residence 4224 South 146th Street RECORDS DIGITAL D- ) EXEMPTION LOG THE ABOVE MENTIONED PERMIT FILE INCLUDES THE FOLLOWING REDACTED INFORMATION Page # tode Exemption = Brief Explanatory DeSctiptiop �t�tutel ule The Privacy Act of 1974 evinces Congress' intent that Personal Information — social security numbers are a private concern. As such, individuals' social security numbers are Social Security Numbers redacted to protect those individuals' privacy pursuant 5 U.S.C. sec. 28,33 DR1 Generally — 5 U.S.C. sec. to 5 U.S.C. sec. 552(a), and are also exempt from 552(a); RCW 552(a); RCW disclosure under section 42.56.070(1) of the 42.56.070(1) 42.56.070(1) Washington State Public Records Act, which exempts under the PRA records or information exempt or prohibited from disclosure under any other statute. Redactions contain Credit card numbers, debit card Personal Information — numbers, electronic check numbers, credit expiration DR2 Financial Information — dates, or bank or other financial account numbers, RCW RCW 42.56.230(4 5) which are exempt from disclosure pursuant to RCW 42.56.230(5) 42.56.230(5), except when disclosure is expressly required by or governed by other law. LABEL RESIDENCE 4224 S 146 ST D08.523 Parcel No.: 0040000462 Address: 4224 S 146 ST TUKW Suite No: Tenant: Name: LABEL RESIDENCE Address: 4224 S 146 ST , TUKWILA WA Owner: Name: LABEL SCOTT +SHARON Address: 4226 S 146TH , SEATTLE WA 98168 Phone: Contact Person: Name: SCOTT LABEL Address: 4226 S 146 ST , TUKVVILA WA 98168 Phone: 206 - 243 -4725 Contractor: Name: LARRY J CASEY CONSTRUCTION Address: 2615 NE 75 ST , SEATTLE WA 98115 Phone: 206 - 527 -1292 Contractor License No: LARRYJC991NM DESCRIPTION OF WORK: ADDITION OF 2 BEDROOMS Value of Construction: Type of Fire Protection: Type of Construction: doc: IBC -10/06 V -B CitAlf Tukwila Department of Community Development 6300 Southcenter Boulevard, Suite #100 Tukwila, Washington 98188 Phone: 206 - 431 -3670 Fax: 206 - 431 -3665 Web site: http: / /www.ci.tukwila.wa.us $29,049.00 DEVELOPMENT PERMIT * * continued on next page ** Permit Number: D08 -523 Issue Date: 02/02/2009 Permit Expires On: 08/01/2009 Expiration Date: 01/30/2011 Fees Collected: $940.05 International Building Code Edition: 2006 Occupancy per IBC: 22 D08 -523 Printed: 02 -02 -2009 Public Works Activities: Channelization / Striping: N Curb Cut / Access / Sidewalk / CSS: N Fire Loop Hydrant: Flood Control Zone: Hauling: Land Altering: Landscape Irrigation: Moving Oversize Load: Permit Center Authorized Signature: Signature: Print Name: doc: IBC -10/06 City (*Tukwila • Department of Community Development 6300 Southcenter Boulevard, Suite #100 Tukwila, Washington 98188 Phone: 206 - 431 -3670 Fax: 206 - 431 -3665 Web site: http: / /www.ci.tukwila.wa.us N N Number: 0 Size (Inches): 0 Start Time: Volumes: Cut 0 c.y. End Time: Fill 0 c.y. Start Time: End Time: Sanitary Side Sewer: Sewer Main Extension: Private: Public: Storm Drainage: Street Use: Profit: N Non - Profit: N Water Main Extension: Private: Public: Water Meter: N Permit Number: D08 -523 Issue Date: 02/02/2009 Permit Expires On: 08/01/2009 )-re)--0 -re)--0 I hereby certify that I have read and examined this permit and know the same to be true and correct. All provisions of law and ordinances governing this work will be complied with, whether specified herein or not. The granting of this permit does not presume to • construction or the j/ -� a of w • ' . � / �� / ve authority to violate or cancel the provisions of any other state or local laws regulating horized to sign and obtain this development pe Date: c This permit shall become null and void if the work is not commenced within 180 days from the date of issuance, or if the work is suspended or abandoned for a period of 180 days from the last inspection. D08 -523 Printed: 02 -02 -2009 Parcel No.: 0040000462 Address: 4224 S 146 ST TUKW Suite No: Tenant: LABEL RESIDENCE 1: ** *BUILDING DEPARTMENT CONDITIONS * ** City of Tukwila Department of Community Development 6300 Southcenter Boulevard, Suite #100 Tukwila, Washington 98188 Phone: 206 - 431 -3670 Fax: 206 - 431 -3665 Web site: http: / /www.ci.tukwila.wa.us PERMIT CONDITIONS Permit Number: D08 -523 Status: ISSUED Applied Date: 12/30/2008 Issue Date: 02/02/2009 2: No changes shall be made to the approved plans unless approved by the design professional in responsible charge and the Building Official. 3: All mechanical work shall be inspected and approved under a separate permit issued by the City of Tukwila Permit Center (206/431 - 3670). 4: All permits, inspection records, and approved plans shall be at the job site and available to the inspectors prior to start of any construction. These documents shall be maintained and made available until final inspection approval is granted. 5: Truss shop drawings shall be provided with the shipment of trusses delivered to the job site. Truss shop drawings shall bear the seal and signature of a Washington State Professional Engineer. Shop drawings shall be maintained on the site and available to the building inspector for inspection purposes. 6: All construction shall be done in conformance with the approved plans and the requirements of the International Building Code or International Residential Code, International Mechanical Code, Washington State Energy Code. 7: Notify the City of Tukwila Building Division prior to placing any concrete. This procedure is in addition to any requirements for special inspection. 8: All wood to remain in placed concrete shall be treated wood. 9: There shall be no occupancy of a building until final inspection has been completed and approved by Tukwila building inspector. No exception. 10: Remove all demolition rubble and loose miscellaneous material from lot or parcel of ground, properly cap the sanitary sewer connections, and properly fill or otherwise protect all basements, cellars, septic tanks, wells, and other excavations. Final inspection approval will be determined by the building inspector based on satisfactory completion of this requirement. 11: All construction noise to be in compliance with Chapter 8.22 of the City of Tukwila Municipal Code. A copy can be obtained at City Hall in the office of the City Clerk. 12: Ventilation is required for all new rooms and spaces of new or existing buildings and shall be in conformance with the International Building Code and the Washington State Ventilation and Indoor Air Quality Code. 13: Except for direct -vent appliances that obtain all combustion air directly from the outdoors; fuel -fired appliances shall not be located in, or obtain combustion air from, any of the following rooms or spaces: Sleeping rooms, bathrooms, toilet rooms, storage closets, surgical rooms. 14: Equipment and appliances having an ignition source and located in hazardous locations and public garages, PRIVATE GARAGES, repair garages, automotive motor -fuel dispensing facilities and parking garages shall be elevated such that the source of ignition is not less than 18 inches above the floor surface on which the equipment or appliance rests. doc: Cond -10/06 D08 -523 Printed: 02 -02 -2009 • • City of Tukwila Department of Community Development 6300 Southcenter Boulevard, Suite #100 Tukwila, Washington 98188 Phone: 206 - 431 -3670 Fax: 206 - 431 -3665 Web site: http: / /www.ci.tukwila.wa.us 15: Water heaters shall be anchored or strapped to resist horizontal displacement due to earthquake motion. Strapping shall be at points within the upper one -third and lower one -third of the water heater's vertical dimension. A minimum distance of 4- inches shall be maintained above the controls with the strapping. 16: All plumbing and gas piping work shall be inspected and approved under a separate permit issued by the Cityof Tukwila Permit Center. 17: All electrical work shall be inspected and approved under a separate permit issued by the City of Tukwila Building Department (206- 431 - 3670). 18: VALIDITY OF PERMIT: The issuance or granting of a permit shall not be construed to be a permit for, or an approval of, any violation of any of the provisions of the building code or of any other ordinances of the City of Tukwila. Permits presuming to give authority to violate or cancel the provisions of the code or other ordinances of the City of Tukwila shall not be valid. The issuance of a permit based on construction documents and other data shall not prevent the Building Official from requiring the correction of errors in the construction documents and other data. doc: Cond -10/06 * * continued on next page ** D08 -523 Printed: 02 -02 -2009 I hereby certify that I have read these conditions and will comply with them as outlined. All provisions of law and ordinances governing this work will be complied with, whether specified herein or not. The granting of this permit does not presume to give authority to violate or cancel the provision of any other work or local laws regulating construction or the performance of work. Signature: Print Name: doc: Cond -10/06 • • City of Tukwila Department of Community Development 6300 Southcenter Boulevard, Suite #100 Tukwila, Washington 98188 Phone: 206 - 431 -3670 Fax: 206 - 431 -3665 Web site: http: / /www.ci.tukwila.wa.us S ce___ (- A�L Date: D08 -523 Printed: 02 -02 -2009 [SITE LOCATION c07r j Mailing Address: ' ZZ4 ' O. C `r ' 5, E -Mail Address: 1/ 1 17 e 1 4) utski . ce,w'J Name: Company Name: Mailing Address: Contact Person: E -Mail Address: Contractor Registration Number: Company Name: 14A Kt C L) / J t Mailing Address: 3 0Q /93 ' f L Contact Person: 14 1 IL- E r it-g.4-414 E -Mail Address: Company Name: Mailing Address: CITY OF TUKWILr' Community Development Department Public Works Department Permit Center 6300 Southcenter Blvd., Suite 100 Tukwila, WA 98188 http://www.ci.tukwila.wa.us Contact Person: E -Mail Address: Q:\Applications\Porms- Applications On Line \3-2006 - Permit Application.doc Revised: 9 -2006 bh Applications and plans must be complete in order to be accepted for plan review. Applications will not be accepted through the mail or by fax. **Please Print** King Co Assessor's Tax No.: � 000 -4:1 (6 Z -03 Site Address: 112-- S ) �6 �' Ti,�Gt�t 1-44 Suite Number: Floor: --- Tenant Name: 0471 Wit+, re- New Tenant: 0 .... Yes g i ..No Property Owners Name: -, SCo T" T c if oEL-- Mailing Address: Zito 50. / t / .- 6Tt1 7' v ,C�u� City u> t iV6 State Zip . :do we contact wh your Permit's ready to he "issue Day Telephone: 24 , 243- 7Z� 7F-ViAllu4 LAM City State / Zip Fax Number: ,6 7--- 7--- , y' - 6 / e or Plu GENER.Ai. COIN: (Contractor Information: J INF I,,. apical (pg:4 bing and Gas Pipin State Zip City Day Telephone: Fax Number: Expiration Date: c E ,Ey' tag. ?° City State Zip 'A Day Telephone: 2-S t./3 Z -1 2 Fax Number: 140/4e- State Zip City Day Telephone: Fax Number: Page 1 of 6 Valuation of Project (contractor's bid price): $ /Q9 e.4. ?) Existing Building Valuation: $ G' Scope of Work (please provide detailed information): 014 / T 4 d,F & 2;0ov s Will there be new rack storage? ❑ .... Yes .. No If yes, a separate permit and plan submittal will be required. 2 oo l La Floors -" Detached Para A li c Det a+ f ed '] ck Uncovered Deck; kO sF 17-0 Sr' 5• iy Occupancy per IBC PLANNING DIVISION: Single family building footprint (area of the foundation of all structures, plus any decks over 18 inches and overhangs greater than 18 inches) *For an Accessory dwelling, provide the following: din Lot Area (sq ft): Floor area of principal dwelling: Floor area of accessory dwelling: *Provide documentation that shows that the principal owner lives in one of the dwellings as his or her primary residence. Number of Parking Stalls Provided: Standard: Will there be a change in use? Yes Q: \Applications\Forms- Applications On Line U-2006 - Permit Application.doc Revised: 9 -2006 bh Compact: Handicap: ❑ No If "yes ", explain: #11 (a LT 5 v/ /iNit E� FIRE PROTECTION/HAZARDOUS MATERIALS: 4 ❑ Sprinklers Automatic Fire Alarm 0 None ❑ Other (specify) Will there be storage or use of flammable, combustible or hazardous materials in the building? ❑ Yes jg No If `yes', attach list of materials and storage locations on a separate 8 -1/2" x 11 " paper including quantities and Material Safety Data Sheets. SEPTIC SYSTEM ❑ On -site Septic System — For on -site septic system, provide 2 copies of a current septic design approved by King County Health Department. Page 2 of 6 Scope of Work (please provide detailed information): 4110/V 7-- 300 5F h Tif t Water District ❑ ...Tukwila 0.. Water District #125 ❑ ...Water Availability Provided Sewer District ❑ ...Tukwila ❑ ...Sewer Use Certificate Septic System: ❑ On -site Septic System — For on -site septic system, provide 2 copies of a current septic design approved by King County Health Department. Submitted with Application (mark boxes which apply): 0...Civil Plans (Maximum Paper Size — 22" x 34 ") ❑ ...Technical Information Report (Storm Drainage) ❑ ...Bond ❑ .. Insurance ❑ .. Easement(s) Proposed Activities (mark boxes that apply): ❑ ...Right -of -way Use - Nonprofit for less than 72 hours .Right -of -way Use - No Disturbance ❑ ...Construction/Excavation/Fill - Right -of -way Non Right -of -way ❑ ...Total Cut ❑ ...Total Fill Please refer to Public Works Bulletin #1 for fees and estimate sheet. cubic yards cubic yards ❑ ... Sanitary Side Sewer ❑ .. Abandon Septic Tank ❑ .. Grease Interceptor ❑ ...Cap or Remove Utilities ❑ .. Curb Cut ❑ .. Channelization ❑ ...Frontage Improvements ❑ .. Pavement Cut ❑ .. Trench Excavation ❑ ...Traffic Control ❑ .. Looped Fire Line ❑ .. Utility Undergrounding ❑ ...Backflow Prevention - Fire Protection Irrigation Domestic Water ❑ ...Permanent Water Meter Size... WO # ❑ ...Temporary Water Meter Size.. WO # ❑ ...Water Only Meter Size WO # ❑...Deduct Water Meter Size ❑ ...Sewer Main Extension Public Private ❑ ... Water Main Extension Public Private FINANCE INFORMATION Fire Line Size at Property Line Number of Public Fire Hydrant(s) ❑ ...Water ❑ ... Sewer ❑ ...Sewage Treatment Monthly Service Billing to: Name: Day Telephone: Mailing Address: Water Meter Refund/Billing: Name: Mailing Address: Q:\ Applications\Fortns- Applications On Line \3 -2006 - Permit Application.doc Revised: 9 -2006 bh Call before you Dig: 1- 800 - 424 -5555 ❑ .. Highline tg ... ValVue ❑ .. Renton 0... Sewer Availability Provided ❑ .. Geotechnical Report ❑ .. Maintenance Agreement(s) ❑ .. Right -of -way Use - Profit for less than 72 hours ❑ .. Right -of -way Use — Potential Disturbance ❑ .. Work in Flood Zone ❑ .. Storm Drainage City Day Telephone: City ❑ ...Renton ❑ ...Seattle ❑ ... Traffic Impact Analysis ❑...Hold Harmless — (SAO) ❑ ... Hold Harmless — (ROW) State Zip State Zip Page 3 of 6 Unit Type: Qty Unit Type: Qty Unit Type: Qty Boiler /Compressor: Qty Furnace <100K BTU Air Handling Unit >10,000 CFM Fire Damper 0 -3 HP /100,000 BTU Furnace >100K BTU Evaporator Cooler Diffuser 3 -15 HP /500,000 BTU Floor Furnace Ventilation Fan Connected to Single Duct Thermostat 15 -30 HP /1,000,000 BTU Suspended /Wall/Floor Mounted Heater Ventilation System Wood /Gas Stove 30 -50 HP /1,750,000 BTU Appliance Vent Hood and Duct Emergency Generator 50+ HP /1,750,000 BTU Repair or Addition to Heat/Refrig /Cooling System Incinerator - Domestic Other Mechanical Equipment Air Handling Unit <10,000 CFM Incinerator — Comm/Ind Contact Person: E -Mail Address: Contractor Registration Number: MYIECHAN1CAL PERMIT !NF %1ATXON - 206 -431 3670 MECHANICAL CONTRACTOR INFORMATION Company Name: Mailing Address: City Day Telephone: Fax Number: Expiration Date: Valuation of Mechanical work (contractor's bid price): $ is10 lA' O yirr Scope of Work (please rov detailed information): gZL . Wirt (..._ Z St-- f-0 do LT. 0 Jv 14c04--r 5 L" tT t y e„1601- P, r'4 J4 1 X l ZM2-t C- ©c)-7 Use: Residential: New Replacement .... LI Commercial: New .... ❑ Replacement .... Fuel Type: Electric Gas ....El Other: Indicate type of mechanical work being installed and the quantity below: Q:\Applications\Forms- Applications On Line\3 -2006 - Permit Application.doc Revised: 9 -2006 bh State Zip Page 4 of 6 Fixture Type: Qty Fixture Type: Qty Fixture Type: Qty Fixture Type: Qty Bathtub or combination bath /shower Drinking fountain or water cooler (per head) Wash fountain Gas piping outlets Bidet Food -waste grinder, commercial Receptor, indirect waste Clothes washer, domestic Floor drain Sinks Dental unit, cuspidor Shower, single head trap Urinals Dishwasher, domestic, with independent drain Lavatory Water Closet Building sewer or trailer park sewer Rain water system — per drain (inside building) Water heater and/or vent Additional medical gas inlets /outlets — six or more Industrial waste pretreatment interceptor, including its trap and vent, except for kitchen type grease interceptors Repair or alteration of water piping and /or water treating equipment Repair or alteration of drainage or vent piping Medical gas piping system serving one to five inlets /outlets for specific gas PI, UMBIN, AND SAS FPY' Contact Person: E -Mail Address: Contractor Registration Number: Valuation of Plumbing work (contractor's bid price): $ Valuation of Gas Piping work (contractor's bid price): $ Scope of Work (please provide detailed information): Q:\Applicationsworms- Applications On Line \3 -2006 - Permit Application.doc Revised: 9 -2006 bh PLUMBING AND GAS PIPING CONTRACTOR INFORMATION Company Name: Mailing Address: City Day Telephone: Fax Number: Expiration Date: Building Use (per Intl Building Code): Occupancy (per Int'l Building Code): Utility Purveyor: Water: Sewer: Indicate type of plumbing fixtures and/or gas piping outlets being installed and the quantity below: State Zip Page 5 of 6 Value of Construction — In all cases, a value of construction amount should be entered by the applicant. This figure will be reviewed and is subject to possible revision by the Permit Center to comply with current fee schedules. Expiration of Plan Review — Applications for which no permit is issued within 180 days following the date of application shall expire by limitation. Building and Mechanical Permit The Building Official may grant one or more extensions of time for additional periods not exceeding 90 days each. The extension shall be requested in writing and justifiable cause demonstrated. Section 105.3.2 International Building Code (current edition). Plumbing Permit The Building Official may grant one extension of time for an additional period not exceeding 180 days. The extension shall be requested in writing and justifiable cause demonstrated. Section 103.4.3 Uniform Plumbing Code (current edition). I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION AND KNOW THE SAME TO BE TRUE UNDER PENALTY OF PERJURY BY THE LAWS OF THE STATE OF WASHINGTON, AND I AM AUTHORIZED TO APPLY FOR THIS PERMIT. BUILDING OWNE Signature: OR AUTHO Print Name: 5f3 Mailing Address: (22-6 Sp • / tits T_' Date Application Expires: to - I Date Application Accepted: 1 Q:\Applications\Forms- Applications On Line\3 -2006 - Permit Application.doc Revised: 9 -2006 bh NT: Date: ( 4 Day Telephone: 10 2 43 ^ 1 4 , 72_S City State Zip Staff Initials: itiz I Page 6 of 6 Parcel No.: 0040000462 Address: 4224 S 146 ST TUICW Suite No: Applicant: LABEL RESIDENCE Receipt No.: R09 -00154 Initials: WER Payment Date: 01/29/2009 02:29 PM User ID: 1655 Balance: $0.00 Payee: SCOTT LABEL TRANSACTION LIST: Type Method Descriptio Amount Payment Check 6428 571.50 ACCOUNT ITEM LIST: Description BUILDING - NONRES STATE BUILDING SURCHARGE PAYMENT RECEIVE City of Tukwila Department of Community Development 6300 Southcenter Boulevard, Suite #100 Tukwila, Washington 98188 Phone: 206 -431 -3670 Fax: 206 -431 -3665 Web site: http://www.ci.tukwila.wa.us RECEIPT Account Code Current Pmts 000/322.100 567.00 000/386.904 4.50 Total: $571.50 Permit Number: D08 -523 Status: APPROVED Applied Date: 12/30/2008 Issue Date: Payment Amount: $571.50 A to G40.234.1 14 doc: Receiot -06 Printed: 01 -29 -2009 Receipt No.: R08 -03991 Initials: WER User ID: 1655 Payee: SCOTT LABEL City of Tukwila Department of Community Development 6300 Southcenter Boulevard, Suite #100 Tukwila, Washington 98188 Phone: 206 - 431 -3670 Fax: 206 -431 -3665 Web site: http: / /www.ci.tukwila.wa.us TRANSACTION LIST: Type Method Descriptio Amount Payment Check 6361 368.55 ACCOUNT ITEM LIST: Description PLAN CHECK - NONRES RECEIPT Account Code Current Pmts Parcel No.: 0040000462 Permit Number: D08 -523 Address: 4224 S 146 ST TUKW Status: PENDING Suite No: Applied Date: 12/30/2008 Applicant: LABEL RESIDENCE Issue Date: 000/345.830 368.55 Total: $368.55 Payment Amount: $368.55 Payment Date: 12/30/2008 03:59 PM Balance: $571.50 0967 12/31 9707 TOTAL 368°55 doc: Receiot -06 Printed: 12 -30 -2008 Pro ect: i be/ 'e°.5. Type of Inspection: F/A/09 / Address: q. 2q .5 / 1 1 —Si Date Called: Special Instructions: Date Wanted: 6 - 70 - 09' p.m. Requester: Phone No: P.06 4 /725 INSPECTION RECORD INSPE Retain a copy with permit .P08 ION NO. PERMIT NO. CITY OF TUKWILA BUILDING DIVISION V 6300 Southcenter Blvd., #100, Tukwila, WA 98188 (2 -3670 ...% ***FApproved per applicable codes. ❑ Corrections required prior to approval. COMMENTS: Inspe ant f / 1 .00 REINSPECTION FE REQU D. Prior to inspection, fee must be aid at 6300 Southcenter lvd., S ite 100. Call to schedule reinspection. Receipt No.: (Date: Project: J'9 &/ ��S Type of 1 p ctio :• /2 dcf(Ie•/IA, Address: Date Called: Special Instructions: m554' Date Wanted: �j - 5 — D c p.m. Requester: Phone No: _do6- 5.3Z -0522 7 PERMIT NO. CITY OF TUKWILA BUILDING DIVISION R. 6300 Southcenter Blvd., #100, Tukwila, WA 98188; INSPECTION NO. INSPECTION RECORD Retain a copy with permit D (206)431 -3670 Approved per applicable codes. COMMENTS: A Of' e • Inspector 60 a dttazi 0 REINSPECTION FEE FEQUIRgD. Prior to inspection, fee must be at 6300 Southcenter Blv , Suit 100. Call to schedule reinspection. Re : pt No.: Date: ❑ Corrections required prior to approval. a • 7)6S-5 INSPECTION RECORD Retain a copy with permit INS CTION, NO. PERMIT NO. CITY OF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd., #100, Tukwila, WA 98188 (206)431 -3670 I I Approved per applicable codes. Corrections required prior to approval. CO ENTS: 0 M ,Pig 4/G --- A /WM /0 wAI /1 --1-- )( heAlit Insp Rec I Date: ❑ $6 .00 REI PECTIdN FEE R E1 p: id at 63 cfSouthcenter Blvd., UIRE !Prior to infspect n, fee,iFtust be it 00. Call to sched le reinspection. Type of Inspection: Addge s /L//6 L�l// YY " Date Called: Special Instructions: Date Want /..J /,t v s a Requester: Phone No. — 3q0 r- 59 9 / 7)6S-5 INSPECTION RECORD Retain a copy with permit INS CTION, NO. PERMIT NO. CITY OF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd., #100, Tukwila, WA 98188 (206)431 -3670 I I Approved per applicable codes. Corrections required prior to approval. CO ENTS: 0 M ,Pig 4/G --- A /WM /0 wAI /1 --1-- )( heAlit Insp Rec I Date: ❑ $6 .00 REI PECTIdN FEE R E1 p: id at 63 cfSouthcenter Blvd., UIRE !Prior to infspect n, fee,iFtust be it 00. Call to sched le reinspection. COMMENTS: / --L 1, 9 // T"Ji' , / A/ d — ,qt'rn - .S /- 4/ 4/ G / 4114C P /1 Address;, ` , s /y6 5-r Date Called: cPZ 1; /f" S / P,Fsv.- /47 i :0 Requester: fi� 5 F� N Pho , c :"/ e) - J © - ' / eve 84' 7/ 4. ii `%'t i /VJ 1 % - Gc/i )vet /ezi 41 D k" T 6 . u 114 a 6.(ii? / / , P ro a A °� A Type of Inspection: rip. fiv/v6 Address;, ` , s /y6 5-r Date Called: Special Instructions: 1 TAe 4. r Date / nted: Requester: fi� 5 F� N Pho , c :"/ e) - J © - INSPE ON NO. CITY OF TUKWILA BUILDING DIVISION K. 6300 Southcenter Blvd., #100, Tukwila, WA 98188 (206)431 -3 •M1 D Approved per applicable codes. Receipt No.: INSPECTION RECORD Retain a copy with permit frA44.5 / tom PERMIT NO. Corrections required prior to approval. Date: e 0.00 REINSPECTION EE REQUIRED. Prior to inspection, fee must be id at 6300 Southcenter Blvd., Suite 100. Call to schedule reinspection. 'Date: Project: ‘ .9 6e/ R .5 . Type of I spection: 0...14- h#'.1 7 A */(4,,t, Address: 922 J(/ S /4'C—/ Date Called:rho.p:'k , Special Instructions: Date Wanted: �-- iZ -eS p.m. Requester: Phone No: �t 4 �aS SZ3 INSPECTION RECORD Retain a copy with permit INSPECTION NO. PERMIT NO. CITY OF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd., #100, Tukwila, WA 98188 (206)431 -3670 Approved per applicable codes. El Corrections required prior to approval. COMMENTS: i AJ& g A ✓ ki ❑ $60.00 REINSPECTION FEE REQUIRED. Prior to inspection, fee must be paid at 6300 Southcepter Blvd., Suite 100. Call to schedule reinspection. Inspecto Date: 3 1 Receipt.to.: 'Date: COMMENTS: Type of I , A p 0 Q % 4 , � t1 D . • l 0`. 4 7 GL42 /AJ/ — 4 MQett6i Date Called: 7 f ,04, , d 0OA/ - r f1i/4SA very /_ .,vf°er'rio 4 Requester: Phone AG' 34 —9 V*' b/ tf � 4- A,4., ,41 r m>i,s - 7 �.'" . --,, -c I � r9T-- - I>.7 1 /� Project: �1 fl. CL C I S✓ • ' ' R�� Type of I , A p 0 Q % 4 , � t1 D . • l 0`. Add '0- 2 '4 S - 1A �o t'- _. Date Called: Special Instructions: OM /1---q q 6 t A tr 95Z^ Date Wanted: - a.as.. , f � of Requester: Phone AG' 34 —9 INSPECTION RECORD Retain a copy with permit INSPECTION NO. CITY OF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd., #100, Tukwila, WA 98188 Jo -523 PERMIT NO. (2 0 -36'0 Approved per applicable codes. YI Corrections required prior to approval. - I D r dms'` pe� 4 $• 0.00 REINSPECTIO FEE REO IRED. Prior to inspection, fee must be • aid at 6300 Southcen er,Blvd. uite 100. Call to schedule reinspection. R eceipt No.: 'Date: .1 Proi'ect�}•� i ) ) (( R. eJ• It specon: t r T e of In /` a & � '" 3l 1 - iii a Adores_s 5D / .ek:9 .9 Date ailed: Special Instructions: Date Wanted: 2, - (N s6 1 . -- - r a.ry ' p.m. Requester: Phone No: /2,4(0'311) 41 D Dc) s -S Z3 INSPECTION RECORD Retain a copy with permit INSPECTION NO. PERMIT NO. CITY OF TUKWILA BUILDING DIVISION 6300 S'oLithceriter Blvd., #100, Tukwila, WA 98188 (206)431 -3670 Approved per applicable codes. Corrections required prior to approval. El $60.00 REINSPECTION FEE REQUIRED. Prior to inspection, fee must be paid at 6300 Southcenter Blvd., Suite 100. Call to schedule reinspection. COMMENTS: r. r .1r J Inspecto( Date: 1 .Z —0 9 Receipt No.: 'Date: COMMENTS: 4 fr ki E ft c-vow A ty ii.',4f a A f it, Address: 4/22q s / /I s7 . 6v -d; n.� , - J A 0A-f 1 A 3T 1 p v hi l i - 1 , dnJ 0r '' d . c.. r:, .� r Gr¢ J 'Oe v 01 U sta.. , k-3r-� Or , iMJ r. 111 ) 1 •qyt___. & /C A -1C J nf.3 r -cit- - AST ‘-1 _ J'c A4 1 5 k " etj 01;1 of i 0 -4 , M( C' le e —, 4 1 &) , . Project: 1 4Aee/ it - Type of Inspection: �4d7 JM 1) ' & Address: 4/22q s / /I s7 Date C f / 0 d fit. Special Instructions: Date Wanted: Requester: Phone No as i 0 -4 INSPECTION NO. INSPECTION RECORD Retain a copy with permit CITY OF TUKWILA BUILDING DIVISIO 6300 Southcenter Blvd., #100, Tukwila, WA 98188 Approved per applicable codes. De ° 57 Corrections required prior to approval. Insper: t u Date _ r 1 _o El $60.00 REINSPECTION FEE REQUIR D. Prior to inspection, fee must be paid at 6300 Southcenter Blvd., Suite 100. Call to schedule reinspection. 'Receipt No.: !Date: 7 PERMIT NO. (206)431 -367 �r- Proje s 1 /C ) s Type of b fo :4 Lki Addr s' •V 1 So i 'l ate Called: St Special Ins ructions: + / n Date Wanted /**-- a.m Requester: Phone No: r 3 ? — ? / INSPECTION RECORD Retain a copy with permit W—SL3 �,(�. V`� PERMIT . PERMIT NO. INSPECTION NO. CITY OF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd., #100, Tukwila, WA 98188 (206)431 -3670 Approved per applicable codes. Corrections required prior to approval. COMMENTS: — 6rre 2_. p/v nspectc r: I te1z_ _ 0 - q 7 ri $60.00 REINSPECTION FEE REQUIRED. Prior to inspection, fee must be paid at 6300 Southcenter Blvd., Suite 100. Call to schedule reinspection. Receipt No.: Date: January 14, 2009 City of Tukwila Dept of Community Development 6300 Southcenter Blvd #100 Tukwila, WA 98188 To Whom It May Concern: • Ao FILE etrrf This letter is in reference to Application #D08 -523. Below are the responses to Correction Letter #1. 1. The intended use of the property is for an Adult Family Home. I currently operate an adult family home next door at 4226 South 146 to this proposed home addition. And I would like to open another one because the demand is high for this type of care. I am not sure as to what TMC number an adult family home is classified under. The closest uses would be 18.06.020 (Adult Day Care) and 18.06.173 (Convalescent/Nursing Home). 2. I plan on securing a business license with the City of Tukwila prior to operating the home as an Adult Family Home. I do have a business license to operate my other adult family home. 3. I have not been issued a license yet, so I am attaching a copy of a completed application. I am unable to include the information on other employees, as they have not been hired as of yet. 4. I am attaching a revised plan showing the entire floor plan of the house. 5. Also in the plan is the parking area now showing the dimensions of the parking space. 6. My future intentions for the other two homes I own to the north are undecided at this time. If demand for adult family homes is there I would probably want to convert those additional two homes to adult family homes in the future. 7. The current employees for the adult family home, located at 4226 South CORR,EG ION RECEIVED LTR #. D08%.523 JAN 14 2009 PERMIT CENTEF • 146 are the owner and two part time employees, as well as six elderly residents. At the new adult family home, located at 4224 South 146 , I will have a resident manager (not the owner), two part time employees and up to six elderly residents. If you have further questions please contact me. Sincerel Sco Label 206 - 243 -4725 SECTION 1 - INFORMATION ABOUT THE PROPOSED ADULT FAMILY HOME 1. NAME OF PROPOSED ADULT FAMILY HOME M 0 11-4 1 N 6 57 D ally" j /c,Y Ho su 1. 2. STREET ADDRESS CITY STATE ZIP CODE Li),-2-ii So. /ytb i. Tv/6)/u/ G _ . 6i 3. MAILI G ADDRESS (IF DIFFERENT, ABOVE) CITY STATE ZIP CODE 924 ( So • f of � • `�aleuth L4 L,t'i4 , 9 i6 g 4. TELEPHONE NUMBER 2€ 6 7k-( -47 ‹. 5. CELL PHONE NUMBER - Z / 3 �7� VL 1-‹ 6. FAX NUMBER 706 / J r6 /y Physical address for applicant (if the applicant is not living at the address for the proposed adult family home). 7. ADDRESS CITY STATE ZIP CODE L(2 50 - !'i 4 . 7 Lit- GvAl- pe6 c You must notify the department if the above address changes. SECTION 2 — LANDLORD INFORMATION 8. Does the individual applicant/entity representative own this home? If "no" is checked above: `_. Yes ❑ No 9. NAME OF LANDLORD 10. LANDLORD'S ADDRESS CITY STATE ZIP CODE 11. Will the landlord take an active interest in the operation of the adult family home by charging rent as a percentage of the business, providing management services, providing care to residents or have any other involvement in the adult family home? . -i Yes ❑ No SECTION 3 - UNIFIED BUSINESS IDENTIFIER (UBI) NUMBER AND FEDERAL EMPLOYER IDENTIFICATION NUMBER (EIN) The following numbers are re•uired for the license application. For information on getting these numbers, see the application instructions. 12. APPLICANTS UBI NUMBER Q , (,� H Jr J�'/ 4 t- /-VA_ [ er �? 13. APPLICANTS EIN NUMBS - itriat / ' i e� / ,L t/ T SECTION 4 - ENTITY Fill out this section ONLY if an entity is applying for the license. An entity is a corporation, partnership, or limited liability individual, mark the N/A box and go to section 6. company (LLC). If you are applying as an 1$ N/A (I am applying as an individual) 14. LEGAL NAME OF ENTITY (NAME LISTED ON THE EIN AND UBI) 15. TELEPHONE NUMBER 16. FAX NUMBER 17. MAILING ADDRESS CITY STATE ZIP CODE SECTION 5 - INDIVIDUALS AFFILIATED WITH APPLICANT (FOR ENTITIES ONLY) Fill out this section ONLY if an entity (a corporation, partnership, or limited liability company (LLC)) is applying for the skip this section and go to section 6. Officers, Directors, and Managerial Employees of the entity. List percentage or greater ownership. If you need more space, provide it on a separate page license. If you are applying as an individual, ❑ N/A (I am applying as an individual) Complete the following table for all Owners, of ownership for all stockholders with 5% and attach it to this application. iADSA Awry . Disability DSHS 10-410 (1221T8R# r CORR E TION ,' FILE COPY rr-rgt Po. Adult Family Home License Application tOBi52 JAN 14 2009 4 PERMIT CENTEF NAME OF PERSON TITLE OR POSITION SOCIAL SECURITY NUMBER DATE OF BIRTH (MM/DD/YYYY) PERCENT OWNERSHIP SECTION 6 - INDIVIDUAL APPLICANT /ENTITY REPRESENTATIVE The individual applicant or the entity representative must complete this section. An entity representative is the person designated by the entity as responsible for the daily operation of the proposed adult family home 18. NAME OF INDIVIDUAL APPLICANT OR ENTITY REPRESENTATIVE (LAST, FIRST, MIDDLE) L nL Sco7T 6a j -tnM►N 19. NAME OF INDIVIDUAL APPLICANT OR ENTITY REPRESENTATIVE AS IT APPEARS ON BIRTH CERTIFICATE ( LAST,FIRST, MIDDLE) S & 20. DATE OF BIRTH it 'i ` f , ‘ 21. SOCIAL SECURITY NUMBER 22. E -MAIL ADDRESS Sbla beI e t1s1.cowl 23. TELEPHONE NUMER IF NOT LIVING IN THE PROPOSED AFH 210 6 L-0s 24. ADDRESS IF NOT LIVING IN THE PROPOS D AFH CITY STATE ZIP CODE q 7,1,6 so . P-4.4. i • 7T4 ?uli Lit WO-- /6 g' SECTION 7 - SPOUSE OR STATE REGISTERED DOMESTIC PARTNER 25. Do you have a spouse or State 26. Do you want your spouse or State family home? ❑ Yes gl No Notes: o If you checked "yes" to licensing requirements. o Couples considered legally spouse. o State Registered Domestic o To be included as a SRDP, the Secretary of State, www.secstate.wa.gov. Registered Domestic Partner (SRDP)? 0 Yes ❑ No Registered Domestic Partner to be listed on the license the question immediately above, both you and your spouse married under Washington state law may not apply for Partners may not apply for separate licenses for each both the applicant and SRDP co- applicant must be registered Corporations Division. For information about State Registered spouse or SRDP is to be listed on the license. for this proposed adult or SRDP must meet all separate licenses for each SDRP. with the Office of Domestic Partners, see Complete below whether or not the 27. NAME OF SPOUSE OR STATE REGISTERED DOMESTIC PARTNER (LAST, FIRST, MIDDLE) 5114720 N t 73rt 28. NAME OF SPOUSE OR STATE REGISTERED , D9MESTIC PARTNER AS IT APPEARS ON BIRTH CERTIFICATE (LAST,FIRST, MIDDLE) sN�oN �YNht KLL- 29. DATE OF BIRTH k 30. SOCIAL DSHS 10 (12/2008) 5 ' SECTION 8 - RESIDENT MANAGER INFORMATIOW This section is to be completed for the person who will be the resident manager of the proposed adult family home. • Every adult family home application must list a resident manager for the proposed adult family home. • A resident manager is a person employed or designated by the provider or entity representative to manage the adult family home. • The resident manager can be the applicant, co- applicant, or other qualified person. However, a person cannot be a resident manager for more than one adult family home. • If our records show that the person you have listed as a resident manager for this proposed adult family home is currently a resident manager for another adult family home, your application will be considered incomplete and you will be asked to designate another qualified person to be the resident manager of your proposed adult family home. 31. NAME OF RESIDENT MANAGER (LAST, FIRST, MIDDLE) t.kor ee7 wN al 5✓ 32. NAME OF RESIDENT MANAGER AS IT APPEARS ON BIRTH CERTIFICATE (LAST,FIRST, MIDDLE) 33. DATE OF BIRTH 34. SOCIAL SECURITY NUMBER SECTION 9 - MINIMUM QUALIFICATIONS Please mark with an "X" in the table below that documentation is provided with this application to verify that each of the following people meets the minimum qualifications: • Individual applicant • Spouse co- applicant or state registered domestic partner co- applicant, • Entity representative, and • Resident Manager Include copies of the required documentation for each person. For the / ONE Li /LO Ve- Ve—r educational requirements (in "a" through "f' below), only one piece of proof is required. INDIVIDUAL APPLICANT SPOUSE CO- APPLICANT OR STATE REGISTERED DOMESTIC PARTNER CO- APPLICANT ENTITY REPRESENTATIVE RESIDENT MANAGER Has a United States high school diploma or general education development certificate, or any English translated government document of the following: a. Successful completion of government approved public or private school education in a foreign country that includes an annual average of one thousand hours of instruction a year for twelve years, or no Tess than twelve thousand hours of instruction (which is the equivalent of grades 1 -12 in the U.S.). If so, you must include a copy of the diploma (foreign language and English translation) and proof of the required number of hours (foreign language and English translation). 94 ❑ ❑ ❑ b. Graduation from a foreign college, foreign university, or United States accredited community college with a two -year diploma, such as an Associate's degree; If so, you must include a copy of the diploma (foreign language and English translation). g ❑ ❑ ❑ DSHS 10-410 (1212008) 6 w INDIVIDUAL APPLICANT SPODE CO- APPLICANT OR STATE REGISTERED DOMESTIC PARTNER CO- APPLICANT ENTITY REPRESENTATIVE RESIDENT MANAGER c. Admission to, or completion of course work at a foreign or United States accredited college or university for which credit were awarded; If so, you must include a copy of the transcript(s) of credits (foreign language and English translation). ❑ ❑ ❑ ❑ d. Graduation from a foreign or United States accredited college or university, including award of a Bachelor's degree; If so, you must include a copy of the diploma (foreign language and English translation). ❑ ❑ ❑ ❑ e. Admission to, or completion of postgraduate course work at a United States accredited college or university for which credits were awarded, including award of a Master's degree; If so, you must include a copy of the transcript(s) of credits. ❑ ❑ ❑ ❑ f. Successful passage of the United States board examination for registered nursing or any professional medical occupation for which college or university education was required. If so, attach a copy of the license. Note: This does not include a Certified Nursing Assistant. ❑ ❑ ❑ ❑ Has completed at least three hundred and twenty hours of successful direct care experience obtained after age eighteen to vulnerable adults in a licensed or contracted setting before operating or managing a home. Note: This information will be verified. 54 • ❑ ❑ Has a valid cardiopulmonary resuscitation (CPR) certificate as required in Chapter 388 -112 WAC. This IN ❑ ❑ ❑ training is usually provided by the American Heart Association and the Red Cross but there may be other training entities. An on -line course does not meet this requirement. Copy both sides of the card /certificate if two sides are completed. Has a valid first -aid card or certificate as required in Chapter 388 -112 WAC. First aid is usually done at the E ❑ ❑ ❑ same time as CPR. Copy both sides of the card /certificate if two sides are completed. Has had tuberculosis (TB) screening test to establish tuberculosis status. TB screening consists of two tests done and read at different times. Consult with your local health department if you have questions. See WAC 388- 76 -10265 through 10310. ❑ ❑ ❑ Has completed Basic or Modified Fundamentals of Caregiving Training. If you meet the requirements of WAC 388 - 112 -0105, you may take the modified basic training instead of basic training. EX ❑ • ❑ Has completed the 48 Hour Administrator Training class for adult family homes. 10 ❑ ❑ NOT REQUIRED DSHS 10-410 (1212008) 7 • SECTION 10 - SPECIALTY TRAINING 35. Check one: residents with dementia, mental illness and /or developmental disabilities. 11. with dementia, mental illness and /or developmental disabilities. If you and care for residents with dementia, mental illness and /or developmental co- applicant or state registered domestic partner co- applicant, must have the required manager "specialty" training. Attach the appropriate below for each person and for each type of specialty training. If you check entity ❑ I do not intend to admit and care for check this box, please go to Section tX I intend to admit and care for residents this box or decide that you want to admit disabilities, the individual applicant, spouse representative, and resident manager specialty training certificates described TYPE OF SPECIALTY TRAINING INDIVIDUAL APPLICANT SPOUSE CO- APPLICANT OR STATE REGISTERED DOMESTIC PARTNER CO- APPLICANT ENTITY REPRESENTATIVE RESIDENT MANAGER Dementia Specialty Training — the specialty training dementia July 2002, completed the class. [. ❑ ❑ ❑ certificate must show the class was for "manager" specialty training. If the class occurred before the certificate MUST show that the person 20 hour "dementia caregiving specialty training" Mental Health Specialty Training — The specialty training mental before July person completed training [ ❑ ❑ ❑ certificate must show the class was for "manager" health specialty training. If the class occurred 2002, the certificate must show that the the 20 hour "mental health caregiving specialty class. Developmental Disability Specialty Training. [ ❑ ❑ ❑ SECTION 11 - PREVIOUS LICENSING OR CONTRACTING EXPERIENCE 36. Has any person or entity named in this adult family home, boarding home, nursing persons with mental illness or developmental If "yes ", provide the information below for application ever owned, held an interest in, managed, or held a license for an home, or other business providing services to children, vulnerable adults, or disabilities? ( Yes ❑ No each person or entity in this application: (Attach additional pages if needed) 37. NAME OF PERSON Sci 1-1413E I-- 38. FACILITY LICENSE TYPE j ULT +l of Howe 39. NAME OF FACILITY Hew( ii I2.isN6 srlf0. �cJLr 6fr oiivy 40. FACILITY CITY AND STATE Tr) k ,v1 LA t th+. 41. POSITION HE L O,vNEL, �f21) a 1 e 42. DATES HELD .2 -0o 7 43. NAME OF PERSON 44. FACILITY LICENSE TYPE 45. NAME OF FACILITY 46. FACILITY CITY AND STATE 47. POSITION HELD 48.DATES HELD 49. NAME OF PERSON 50. FACILITY LICENSE TYPE 51. NAME OF FACILITY 52. FACILITY CITY AND STATE 53. POSITION HELD 54. DATES HELD 55. Has any person or entity named in this application ever held a contract to provide services to children, vulnerable adults, or persons with mental illnesses or developmental disabilities? ❑ Yes ❑ No If "yes ", provide the information below for each person or entity in this application: (Attach additional pages if needed) DSHS 10 -410 (12/2008) 8 NAME OF PERSON TYPE OF CONTRACT STATE DATES HELD • 56. Has any person or entity named in this application now or previously been under investigation by a professional licensing agency, Division of Licensing Resources, a state licensing or contracting agency, Division of Children and Family Services, Child Protective Services, Adult Protective Services or the police for any disciplinary action or for abuse, neglect, exploitation or misappropriation of property of any person? ❑ Yes cid No 57. Has any person or entity named in this application now or previously been denied a contract, license or license renewal to operate a facility providing care to adults or children? ❑ Yes 0 No 58. Has any person or entity named in this application been certified, licensed or contracted with to provide care or services to adults or children, and: a. had such certification or license revoked, suspended, suspended with stay, enjoined, or imposed with conditions, civil fine or stop placement? ❑ Yes Ed No b. had a Medicaid or Medicare provider agreement revoked, cancelled, suspended or not renewed? ❑ Yes 541 No c. relinquished or returned such certification or license; or did not seek the renewal of certification or license when notified by the state agency of initiation of denial, suspension, cancellations, or revocation of certificate, license, or contract? ❑ Yes 0 No If the answer is "yes ", to any of the above questions (numbers 56 - 58) you must provide the following on a separate sheet of paper and attach it to this application: • Name of the individual; • Effective date of license or certification; • Date of action taken; • Type of action taken; • Name and address of facility; • Name and address of agency that took the action; and • Circumstances. SECTION 12 - BACKGROUND INFORMATION List below and attach a completed Background • Individual Applicant • Individual Applicant's Spouse or • Entity Owners, Partners, Officers, • Entity Representative • Resident Manager • Landlord of the proposed adult family access to residents in the adult • Persons age 11 or older who currently residents in the adult family home. You can print out the Background Do not complete Background Authorizations Do not include residents. Authorization form for the following: State Registered Domestic Partner Directors, and Managerial Employees (Includes all members of a corporation) home if they will live, work, volunteer, or otherwise have unsupervised family homes. or who will live, work, volunteer, or otherwise have unsupervised access to Authorization form from: www.dshs. wa.gov /msa/bccu /bccu - forms.htm. for other children age 10 or under. DSHS 10-410 (12/2008) 9 Background Authorization forms must Results from a Background Inquiry Note: If you do not include background have ALL blanks filled in or the license applica ion will be returned without action. for anyone listed above, the department will return the activities until the background authorizations have been are not accepted. authorization forms proceed with licensing application as incomplete and will not provided. 59. NAME OF PERSONS AGE 11 OR OLDER (Attach additional sheets of paper if needed) DAT OF BIRTH SOCIAL SECURITY NUMBER RELATIONSHIP TO APPLICANT 5C-0 rr 1.- � / I )- l i t 7 < C4 60. List below any person named in this application that was or is currently employed by the State of Washington. NAME OF PERSON JOB TITLE/AGENCY NAME DATES OF EMPLOYMENT WITH THE STATE OF WASHINGTON (MONTH/YEAR) If none, check here g N/A 61. List below any person named in this application whom is over the age of 18 and has lived in another state in the past three years. Also, contact the application unit at 360 - 725 -2420 regarding the out-of -state background check process before you submit this application. NAME OF PERSON OUT OF STATE ADDRESS DATES LIVED IN OTHER STATE(S) (MONTH/YEAR) If none, check here (g. N/A 62. List any person named in this application who is over the age of 18 and has lived in another country in the past three years. NAME OF PERSON COUNTRY DATES LIVED IN OTHER COUNTRY (MONTH/YEAR) If none, check here %I N/A DSHS 10-410 (12/2008) 10 • SECTION 13 - FINANCIAL ASSESSMENT INFORMATION Answer this section for the individual applicant, spouse co- applicant or state registered domestic partner co- applicant, entity applicant, entity representative, resident manager, partners, officers, directors or managerial employees of the entity, and owner of 5% or more of the entity. Place an "x" in the appropriate "yes" or "no" boxes below. Attach additional sheets of paper if needed. 63. Have you ever filed for bankruptcy? ❑ Yes 54 No If "yes ", provide the following: NAME OF THE INDIVIDUAL WHAT TYPE OF BANKRUPTCY WAS FILED? DATE FILED DATE CONCLUDED NAME OF THE INDIVIDUAL WHAT TYPE OF BANKRUPTCY WAS FILED? DATE FILED DATE CONCLUDED 64. Have any judgments ever been filed against you or the entity? ❑ Yes Ds No If "yes ", provide the following: NAME OF THE INDIVIDUAL DATE OF JUDGMENT COUNTY AND STATE DESCRIBE THE CIRCUMSTANCES SECTION 14 - CONSENT TO RELEASE AND /OR USE CONFIDENTIAL INFORMATION The individual applicant, spouse, or state registered domestic partner co- applicant, entity representative, entity's officers, director or owner, and resident manager must each sign this section. I consent to the release and use of confidential information about me within the Department of Social and Health Services (DSHS) for purposes of licensing. I grant permission to DSHS and any agency, division, office, or the police to use my confidential information and disclose it to each other for these purposes. Information may be shared verbally or by computer, mail, or hand delivery. I am aware that the department is required to respond to requests for disclosure of information from the public. The department may only withhold information if a specific disclosure exemption exists. (RCW 42.56, Chapter 388 -01 WAC). Completion of this form allows the use and sharing of confidential information within DSHS and with the individual applicant or entity representative for application processing purposes. DSHS may disclose and receive confidential information from outside agencies, divisions, offices and /or the police. This consent is valid for as long as I am the person named in this application. A copy of this form is valid for my permission to release and use this information. NAME OF INDIVIDUAL APPLICANT 5C-err Z-4 SIGNATU - i ,, , 1 % DATJI J 3/ay NAME OF SPOUSE OR STATE REGISTERED DOMESTIC PARTNER SIGNATURE DAT NAME OF ENTITY REPRESENTATIVE SIGNATURE DATE NAME OF OFFICER, DIRECTOR, OWNER OF 5% OR MORE OF THE APPLICANT: SIGNATURE DATE NAME OF OFFICER, DIRECTOR, OWNER OF 5% OR MORE OF THE APPLICANT: SIGNATURE DATE NAME OF OFFICER, DIRECTOR, OWNER OF 5% OR MORE OF THE APPLICANT: SIGNATURE DATE NAME OF OFFICER, DIRECTOR, OWNER OF 5% OR MORE OF THE APPLICANT: SIGNATURE DATE NAME OF OFFICER, DIRECTOR, OWNER OF 5% OR MORE OF THE APPLICANT: SIGNATURE DATE NAME OF RESIDENT MANAGER SIGNATURE DATE DSHS 10.110 (12/2008) 11 SECTION 15 - CERTIFICATION I certify, under the penalty of perjury under the laws of the State of Washington and by my signature, that the information provided in this application and all additional documents and forms required for licensure of an adult family home are true, complete, and accurate. I understand that the department may obtain additional information, verification and /or documentation related to my answers or information. I certify that the applicant, spouse co- applicant, or State Registered Domestic Partner co- applicant, entity representative, and resident manager are at least 21 years of age or older. Copies of all documents needed to verify the items in this application are attached, and original documents will be readily available for the licensor. I understand that failure to accurately answer or fully complete the questions on this application may result in denial of the application, termination of a license, or other sanctions as allowed by law. I understand that the department may check the credit of the corporation or business and its principals; obtain a credit report; and verify any responses provided. The department will use such information and may disclose this information to other parts of the department as appropriate. The department may define some or all of such information as public information and also disclose this information to third parties when requested according to law to the extent that such information is not exempt from such disclosure by state or federal law. I understand and agree that the information I give to the department will be used to verify the information in this application. Any information I give to the department may be used by the department for this purpose. I understand that if I am licensed to operate more than one adult family home that the department will perform an individual credit history check per WAC 388 -76- 10035. I understand that if my application for an adult family home license is denied, I may request an administrative fair hearing within 28 days of receiving the denial letter from DSHS. I have read Chapters 70.128, 70.129, 74.34 RCW, and 388 -76, 388 -112, and 388 -110 WAC, and any other applicable laws and rules. If/when I am licensed:. • I understand that any resident manager I employ must meet the requirements of RCW 70.128.120 and WAC 388- 76- 10130. • No residents receiving care and service in the adult family home will be subject to discrimination on the basis of race, color, national origin, gender, age, religion, creed, marital status, disabled or Vietnam veteran's status, or the presence of any physical, mental, or sensory disability. • If any residents need delegated care, I will make sure that the care is delegated by a registered nurse, according to state law and rules. • I will use the approved floor plan and will not change the use of any room until the local building inspector, if required, and the Residential Care Services field office have reviewed and approved the changes. • I will not exceed the approved capacity of the adult family home, and will contact the Residential Care Services field office before making any capacity changes. I certify and declare under penalty of perjury under the laws of the State of Washington that the information in this application and all of the supporting documents are true and correct to the best of my knowledge. DSHS 10 -410 (12/2008) 12 'SIGNATURE OF APP I ,' // ANT 0 ENT - R -:7 d TATIVE AUTHORIZED TO COMPLETE THIS A LICATION i ir � / ' , PRINT NAME ,..-, 4 L,073e'L DAYTIME TELEPHONE NUMBER 2 2 V 2 - S DATE i 0 / CITY AND STATE WHERE SIGNED TOLwic. 4 W A 9114 Sr Signature Spouse Co- Applicant or State Registered Domestic Partner Co- Applicant (only complete this area if the Spouse or State Registered Domestic Partner is also applying to be licensed for this proposed adult family home). PRINT NAME DAYTIME TELEPHONE NUMBER SIGNATURE DATE CITY AND STATE WHERE SIGNED DSHS 10-410 (1212008) 13 January 9, 2009 Scott Label 4226 S 146 St Tukwila, WA 98168 RE: CORRECTION LETTER #1 Development Application Number D08 -523 Label Residence — 4224 S 146 St Dear Mr. Label, • City of Tukwila Department of Community Development Jack Pace, Director This letter is to inform you of corrections that must be addressed before your development permit can be approved. All correction requests from each department must be addressed at the same time and reflected on your drawings. I have enclosed comments from the Planning Department. At this time, the Building, Fire and Public Works Departments have no comments. Planning Department: Stacy MacGregor at 206 - 433 -7166 if you have questions regarding the attached comments. Please address the attached comments in an itemized format with applicable revised plans, specifications, and/or other documentation. The City requires that four (4) complete sets of revised plans, specifications and/or other documentation be resubmitted with the appropriate revision block. In order to better expedite your resubmittal, a `Revision Submittal Sheet' must accompany every resubmittal. I have enclosed one for your convenience. Corrections /revisions must be made in person and will not be accepted through the mail or by a messenzer service. If you have any questions, please contact me at (206) 431 -3670. Sincerely, Bill Rambo Permit Technician encl File No. D08 -523 P:\Pennit Center\Correction Letters \2008\DO8 -523 Correction Ltr #I.DOC wer • Jim Haggerton, Mayor 6300 Southcenter Boulevard, Suite #100 0 Tukwila, Washington 98188 0 Phone: 206 - 431 -3670 0 Fax: 206 - 431 -3665 • • PLANNING DIVISION COMMENTS DATE: January 7, 2009 APPLICANT: Label Residence: Adult Family Home RE: D08 -523 ADDRESS: 4224 S 146 St Please review the following comments listed below and submit your revisions accordingly. If you have any questions on the requested revision, Stacy MacGregor is the planner assigned to the file and can be reached at 206 -433 -7166. 1) Please describe in more detail the intended use of the property. Tukwila Municipal Code (TMC) defines the following uses, one or more of which may apply. Of the following list of possible uses, dwelling units are permitted outright in the LDR zone where your property is located; Adult Day Care and Home Occupations are each permitted as an accessory use to a permitted use such as a dwelling containing an adult day care or a home occupation. 18.06.020 Adult Day Care "Adult day care" means a facility which provides supervised daytime programs where up to six frail and /or disabled adults can participate in social, educational, and recreational activities led by paid staff and volunteers. (Ord. 1758 §1(part), 1995) 18.06.173 Convalescent/Nursing Home "Convalescent/nursing home" means a residential facility, such as a hospice, offering 24 -hour skilled nursing care for patients suffering from an illness, or receiving care for chronic conditions, mental or physical disabilities or alcohol or drug detoxification, excluding correctional facilities. Care may include in- patient administration of special diets, bedside nursing care, and treatment by a physician or psychiatrist. (Ord. 1976 §13, 2001) 18.06.178 Correctional Institution "Correctional institution" means public and private facilities providing for: 1. the confinement of adult offenders; or 2. the incarceration, confinement or detention of individuals arrested for or convicted of crimes whose freedom is partially or completely restricted other than a jail owned and operated by the City of Tukwila; or 3. the confinement of persons undergoing treatment for drug or alcohol addictions whose freedom is partially or completely restricted; or 4. transitional housing, such as halfway houses, for offenders who are required to live in such facilities as a condition of sentence or release from a correctional facility, except secure community transitional facilities as defined under RCW 71.09.020. (Ord. 1991 §1, 2002; Ord. 1976 §14, 2001) 18.06.260 Dwelling Unit "Dwelling unit" means the whole of a building or a portion thereof providing complete housekeeping facilities for a group of individuals living together as a single residential community, with common cooking, eating and bathroom facilities, other than transitory housing or correctional facilities as defined in this code, which is physically separated from any other dwelling units which may be in the same structure. (Ord. 1976 §7, 2001; Ord. 1758 §1(part), 1995) 18.06.430 Home Occupation "Home occupation" means an occupation or profession which is customarily incident to or carried on in a dwelling place, and not one in which the use of the premises as a dwelling place is largely incidental to the occupation carried on by a resident of the dwelling place; provided, that: 1. There shall be no change in the outside appearance of the surrounding residential development; 2. No home occupation shall be conducted in any accessory building; 3. Traffic generated by such home occupations shall not create a nuisance; 4. No equipment or process shall be used in such home occupation which ® • creates noise, vibration, glare, fumes, odor, or electrical interference detectable to the normal senses off the lot; 5. The business involves no more than one person who is not a resident of the dwelling; and 6. An off - street parking space shall be made available for any non - resident employee. (Ord. 1974 §11, 2001; Ord. 1758 §1(part), 1995 18.06.708 Senior Citizen Housing "Senior Citizen Housing" is housing in a building or group of buildings with two or more dwelling and /or sleeping units, restricted to occupancy by at least one senior citizen per unit, and may include Food Preparation and Dining activities, Group Activity areas, Medical Supervision or other similar activities. Such housing is further distinguished by the use of funding restrictions, covenants between the developer, tenants, operators and /or the City or other agreements that restrict the development to those individuals over 60 years of age. Senior Citizen Housing strategies may include provisions for units dedicated to persons under 60 years of age that have medical conditions consistent with definitions in the Americans with Disabilities Act; however, the population of disabled individuals may not exceed 20% of the residents. These facilities may not include populations requiring convalescent or chronic care, as defined under RCW 18.51. (Ord. 1795 §1(part), 1997) 18.06.743 Shelter "Shelter" means a building or use providing residential housing on a short-term basis for victims of abuse and their dependents, or a residential facility for runaway minors (children under the age of 18). (Ord. 1976 §16, 2001) 2) Prior to operating as an adult family home, a business license with the City of Tukwila is required. If this is a home -based business, describe how the intended business meets the "Home Occupation: Conditions for Issuance of Business License" from the Tukwila Business License Application, see below: Home Occupation: Conditions for Issuance of Business License Pursuant to Tukwila Municipal Code Section 18.06.430 and City policy, home occupations (businesses conducted in and out of a residence or apartment) are defined and must comply with certain conditions, as follow: 18.06.430 Home occupation. "Home occupation" means an occupation or profession which is customarily incident to or carried on in a dwelling place, and not one in which the use of the premises as a dwelling place is largely incidental to the occupation carried on by a member of the family residing within the dwelling place; provided, that: 1. There shall be no change in the outside appearance of the surrounding residential development; 2. No home occupation shall be conducted in any accessory building; 3. Traffic generated by such home occupations shall not create a nuisance; 4. No equipment or process shall be used in such home occupation which creates noise, vibration, glare, fumes, odor, or electrical interference detectable to the normal senses off the lot; 5. The business involves no more than one person who is not a resident of the dwelling; and 6. An off - street parking space shall be made available for any non - resident employee. The above conditions are interpreted to mean at a minimum that: • Employees do not come to the property on a daily or weekly basis. • No more than one work car will be parked on or near the property at any one time. • Outside storage of materials will not occur. • Customers do not come to the premise (with the exception of day cares). The business operator visits customers at their location. • The interior of the premises appears primarily to be a residence. • • 3) Provide a copy of the license required from DHSH or other state agency to operate an adult family home. If a license has not yet been issued, provide a copy of the completed application. 4) Include the floor plan in its entirety. Staff needs to verify the number of bedrooms on the site. 5) Show the parking on the site and call out the parking dimensions on the plan so staff can verify the parking provided meets code. 6) You are already operating Morning Star Adult Family Home on the parcel to the south and you also own the two parcels to the north. Describe your future intentions for these parcels. 7) A review of your business license for the Morning Star Adult Family Home located at 4226 S 146 Street states that in 2007 the sole employee was the owner and in 2008 there were 2 part-time employees. Clarify the employee, owner, resident, resident -owner nature of the people residing and working at both homes (now and the future intent). ACTIVITY NUMBER: D08 -523 DATE: 01 -14 -09 PROJECT NAME: LABEL RESIDENCE SITE ADDRESS: 4224 S 146 ST Original Plan Submittal X Response to Correction Letter # 1 Revision # After Permit Issued Response to Incomplete Letter # DEPARTMENTS: Building Division Public Works • rig Y PLAN REVIEW /ROUTING SLIP Fire Prevention Structural DETERMINATION OF COMPLETENESS: (Tues., Thurs.) Complete Comments: Please Route Notation: Documents/routing slip.doc 2 -28 -02 TUES/THURS RING: REVIEWER'S INITIALS: REVIEWER'S INITIALS: Incomplete Structural Review Required APPROVALS OR CORRECTIONS: Approved Approved with Conditions n Ap Planning Division n Permit Coordinator DUE DATE: 01 -15 -09 Not Applicable Permit Center Use Only INCOMPLETE LETTER MAILED: LETTER OF COMPLETENESS MAILED: Departments determined incomplete: Bldg ❑ Fire ❑ Ping ❑ PW ❑ Staff Initials: n No further Review Required DATE: DUE DATE: 02 -12 -09 Not Approved (attach comments) Ti DATE: Permit Center Use Only CORRECTION LETTER MAILED: Departments issued corrections: Bldg ❑ Fire ❑ Ping ❑ PW ❑ Staff Initials: ACTIVITY NUMBER: D08 -523 PROJECT NAME: LABEL RESIDENCE SITE ADDRESS: 4224 S 146 ST X Original Plan Submittal Response to Correction Letter # DATE: 12 -30 -08 Response to Incomplete Letter # Revision # After Permit Issued DEPARTMENTS: Bung Qivision Public Works Ininn 1- DETERMINATION OF COMPLETENESS: (Tues., Thurs.) Complete Comments: TUES/THURS ROUTING: Please Route REVIEWER'S INITIALS: APPROVALS OR CORRECTIONS: Documents /routing slip.doc 2 -28 -02 SINN CpUU 4' w_'Y:'t`' y • PLAN REVIEW /ROUTING SLIP - 51( Kitt, 1 ' Fire Prevention Structural Incomplete Structural Review Required n P ang lo " U Permit Coordinator DUE DATE: 01 -06 -09 Not Applicable n Permit Center Use Only INCOMPLETE LETTER MAILED: LETTER OF COMPLETENESS MAILED: Departments determined incomplete: Bldg ❑ Fire ❑ Ping 111 PW ❑ Staff Initials: n No further Review Required DATE: DUE DATE: 02 -03-09 Approved Approved with Conditions n Not Approved (attach comments) 1 Notation: REVIEWER'S INITIALS: DATE: Permit Center Use Only CORRECTION LETTER MAILED: 1 - 9 - oq Departments issued corrections: Bldg ❑ Fire ❑ Ping PW ❑ Staff Initials: Date: Entered in Permits Plus on Response to Correction Letter # Response to Incomplete Letter # Received at the City of Tukwila Permit Center by: \applications\forms- applications on Iine\revision submittal Created: 8 -13 -2004 Revised: City of Tukwila Department of Community Development 6300 Southcenter Boulevard, Suite #100 Tukwila, Washington 98188 Phone: 206 - 431 -3670 Fax: 206 -431 -3665 Web site: http: / /www.ci.tukwila.wa. us Revision submittals must be submitted in person at the Permit Center. Revisions will not be accepted through the mail, fax, etc. Plan Check/Permit Number: Summary of Revision: Luq'N 1 J v5 r GM 7 T? 4 v L- r ' L Y hio wr r / c4-77 dL 77ous H u ii- J H-07 ❑ Revision # after Permit is Issued ❑ Revision requested by a City Building Inspector or Plans Examiner Project Name: L,etAki, /�-er11 • CC Project Address: (- Z?_-/ S©. /ti 4 Contact Person: 5 6.0 TY t P S L Phone Number: 200 Z ( 3 '/72 Sheet Number(s): "Cloud" or highlight all areas of revision including date of revision Steven M. Mullet, Mayor Steve Lancaster, Director CITY OF TUKWILA IAN .1 4 2009 NTEP Bond Bond Company Name Bond Account Number Effective Date Expiration Date Cancel Date Impaired Date Bond Amount Received Date 2 CBIC SF6235 06/04/2004 Until Cancelled $12,000.0007/28 /2004 1 CUMBERLAND CASUALTY8:SURETYMB00800559608 CO C11SF6235 /14/2001 Until Cancelled 08/14/2003 $12,000.0008/14 /2001 Insurance Company Name Policy Number Effective Date Expiration Date Cancel Date Impaired Date Amount Received Date 3 CBIC C11SF6235 06/04/200606/04 /2009 $300,000.0005/19 /2008 2 CBIC C11SF6235 06/04/200406/04 /2006 $300,000.0007/13 /2005 1 MARYLAND CASUALTY CO Q61348891- 1 08/14/200108/14 /2002 08/14/2001 Name Role Effective Date Expiration Date CASEY LARRY J OWNER 08/14/2001 Untitled Page 0 • General /Specialty Contractor A business registered as a construction contractor with L81 to perform construction work within the scope of its specialty. A General or Specialty construction Contractor must maintain a surety bond or assignment of account and carry general liability insurance. Business and Licensing Information Name Phone Address Suite /Apt. City State Zip County LARRY J CASEY CONSTRUCTION 2065271292 2615 NE 75TH ST SEATTLE WA 98115 KING Business Type Individual Parent Company UBI No. Status License No. License Type Effective Date Expiration Date Suspend Date Previous License Next License Associated License Specialty 1 Specialty 2 600123755 ACTIVE LARRYJC991NM CONSTRUCTION CONTRACTOR 8/14/2001 1/30/2011 GENERAL UNUSED Business Owner Information Bond Information Page 1 of 1 Insurance Information https: // fortress. wa. gov /lni/bbip/Detail.aspx ?License= LARRYJC991NM 02/02/2009 N 81 55' 20" W 29.11 LEGAL DESCRIPTION N 81 55' 20" W 120.18 = SITE PLAN i J013 SITE 4224 5 146 ST TUGWIL,4 WA 9631663 1—.5 14 31' 46" E 9.88 N815'20 "W 53.13 LOT AREA 8025 sc{. ft. 4224'6 .146TH.ST 98168 ADAMS HOME TRS PARCEL B TGW PORTION OF C OF CITY OF TUKWILA SHORT PLAT NO 91 -01 -65 RECORDING NO 9110301320 SAID SHORT PLAT DAF - TRACT 19 BLOCK 3 OF ADAMS HOME TRACTS - AKA LOT 1 OF CITY OF TUKWILA LOT LINE ADJUSTMENT NO L94 -0015 RECORDING NO 9409211131 DAF - N 60 FT OF S 168.40FT OF TRACT 19 TGW NW CORNER OF N 60 FT OF S 165.40 FT SAID TRACT 19 TH N 01 -06 -40 E 514 FT TH S 81 -55 -20 E 29.11 FT TH 6 83 -24 -45 E 36.41 FT TH S 14 -31-46 E 9.88 FT TO N LINE OF SAID N 60 FT OF S 168.40 FT OF LOT I9 TH N 81 -55-20 W 15.66 FT TO W LINE OF SAID OF TRACT 19 AND POB tae SEPARATE PERMIT REQUIRED FOR: Ef Mechanical Notectrical rWlumbing Is/f as Piping CIty of Tukwila BUILDING DIVISION' rti Lt. Pula r ^vj tp; visit lJSt �I • - • 1c cl i'/G£d* IC1 rovc i F I; 'f i • i�sr _ Cry 1 � X - 1 tt Fit p REVISIONS No changes shall be made to the scope of work without prior approval of Tukwila Building Division. I t Rovi .ions will require a new plan submittal : :;ude additional plan review fees. olty • • • 1 ? TOTAL 177 of VICINITY MAP 4224 5 146 ST TUKWILA WA 981663 I! urala PROJECT DESCR IPTION 12'x 25' 'ADDITION (2) 1BEDROOMS. 300s.f. UIWIN AREA EXISTING BUILDING 1410 s,f, ADDITION 300 s,f, r12 s, f , LOT AREA S025 sf TABLE OF CONTENTS 1 COVER SHEET 2 FOUNDATION AND FLOOR FRAMING 3 FLOOR FLAN ei r41 ROOF FRAMING CORC TIC. S IBUILDINCrt AND WALL SECTION ittvi veu t CODE COMPLIANCE APPROVED JAN 2 7 2009 City Of Tukwila jam DIVISION JAi 't 4 LUUki Faita`1 T! R 6 ELEVATION TjQ V .. 52 3 I_ 10 FOUNDATION: EXTEND FOOTING TO FIRM UNDISTURBED 50 /L, ASSUMED BEARING CAPACITY OF 2000 PSF. ALL EXTERIOR FOOTINGS SHALL EXTEND ,4 MINIMUM OF 12" BELOW ADJACENT EXTERIOR FINISHED GRADE CAST -IN -PLACE CONCRETE- <SPEC /AL INSPECTION NOT REQUIRED.) F "c =2500 PSI a 28 DAYS. MINIMUM 5 -I /2 SACKS OF CEMENT PER CUBIC YARD OF CONCRETE AND A MAXIMUM OF 6-3/4 GALLONS OF WATER PER 94* SACK OF CEMENT. NO SPECIAL INSPECTION REQUIRED, MAX /MUM SIZED AGGREGATE IS / -I /2 /NCHES. MAXIMUM SLUMP l5 4 INCHES. ALL PHASES OF WORK PERTAINING TO THE CONCRETE CONSTRUCTION SHALL CONFORM TO THE BUILDING CODE REQUIREMENTS FOR REINFORCED CONCRETE. ALL REINFORCING STEEL DOWELS, ANCHOR BOLTS AND OTHER INSERTS SHALL BE SECURED IN POSITION PRIOR TO POURING CONCRETE. ANCHOR BOLTS FOR PRESSURE TREATED SILL PLATES TO FOUNDATION WALLS TO BE 5/8 DIAMETER WITH 7 /NCH MINIMUM EMBEDMENT INTO CONCRETE AND MAXIMUM SPACING OF 6 FEET ON CENTER UNLESS NOTED OTHERWISE ON THE PLANS, MINIMUM 2 BOLTS PER SILL PLATE. ONE BOLT TO BE PLACED WITHIN 12 INCHES OF EACH END OF SILL PLAT 6" } *4 *4 *4 NEW FOUNDATION EXISTING FOUNDATION SECTION SCALE 1" = 1' -0" Bo- FLAN SCALE 1" = 1' -0" REINFORCING STEEL: ALL REINFORCING STEEL SHALL BE PLACID IN CONFORMANCE WITH THE BUILDING CODE REQUIREMENTS FOR REINFORCED CONCRETE AND THE MANUAL OF STANDARD PRACTICE FOR REINFORCED CONCRETE CONSTRUCTION BY CR/SL DEFORMED REINFORCING STEEL BAR5 514ALL CONFORM TO ASTM GRADE 40 FOR *5 AND SMALLER BAR5 AND GRADE 60 FOR *6 AND LARGER BARS. ALL REINFORCING BAR BENDS SHALL BE COLD, WITH A MINIMUM RADIUS OF 6 BAR DIAMETERS 6=-7" MINIMUM). CORNER BARS (2' -O" BEND) SHALL BE PROVIDED FOR ALL HORIZONTAL REINFORCEMENT. LAP ALL BARS A MIN /MUM OF 48 BAR DIAMETERS UNLESS NOTED OTHERW 15.E UNLESS OTHERWISE NOTED ON THE DRAWINGS REINFORCING STEEL SHALL HAVE THE FOLLOWING MINIMUM COVER: CONCRETE CAST EARTH 3 INCHES CONCRETE EXPOSED TO EARTH OR WEATHER: *6 THROUGH *I8 BARS *5 BAR AND SMALLER *4 REBAR x 24" EPDXIED 4" INTO EXISTING FOUNDATION (2) AT STEM WALL AND (2) AT FOOTING 2 /NCI-/E5 I -1/2 (NC1-1E5 UNDER -FLOOR AREA = 300 sq. ft. REQUIRED VENTILATION = 2 sq. ft. UNDER -FLOOR VENTILATION EXPANSION AND EPDXY GROUTED ANCHORS: PROVIDE MIN. (4) 1 "x 14" VENTS AS SHOWN. ( 2.1 sq. ft. ) EXISTING FOUNDATION 6" STEM WALL W/ (I) *4 BAR HORIZ. CONT. AND *4 BAR 16" OC VERT W/ 4" HOCK. FTG 8 IS" W/ (2) *4 CONT. SCALE 1" = 1' -0" PROVIDE MIN. IS "x 24" ACCESS SIM 2 2 a 4 EXPANSION ANCHORS INTO CONCRRETE SHALL BE WEDGE -ALL ANCHORS ,45 MANUFACTURED BY 5 /11P5ON STRONG TIE COMPANY INSTALLED IN ACCORDANCE WITH THEIR RECOMMENDATIONS. EPDXY GROUTED ANCHORS SHALL BE INSTALLED USING "SET" EPDXY AS MANUFACTURED BY THE SIMPSON STRONG TIE COMPANY. INSTALLATION SHALL BE IN ACCORDANCE WITH THE MANUFACTURERS RECOMMENDATIONS. • D .4 D° d a MINIMUM NET AREA OF VENTILATION Q ''ENINGS SHALL NOT BE LESS THAN 1 SQUARE FOOT FOR EACH 150 SQUARE FEET OF UNDER FLOOR AREA. ONE SUCH VENTILATING OPENING SHALL BE WITHIN (3) FEET OF EACH CORNER OF THE BUILDING. 2x LEDGER W/ 1/2" DIA x 4" LAG SCREW AT 12" OC ( STAGGER ) 2x10 *2 HEM -FIR AT 16" OC SIMPSON LLS210 EXIST, 6" FND WALL AND 6"x12" FTG A d D < 4 a v NORTH •1 "x 14" VENT (4) AS SHOWN ( SEE UNDER -FLOOR VENTILATION THIS SHT.) 6 MIL BLACK VS 25' -0" 16d AT 4 "OC MIN (1) * 4 CONT. WITHIN TOP 12" OF WALL 5" CONC. WALL W/ *4 BAR VERTICAL AT 24" 00 W/ 4" HOOK AT FTG. HORIZONTAL AT 24" OC EXISITNG CRAWL SPACE AT 45" 00 W/ GALV. 3 "x3 "x1/4" PLATE WASHER 10 Q a D a • Q___ • v 8 "x16" FTG. W/ TYPICAL MUD SILL P.T. 2x6 W/ 5/5" DIA. x 10" ANCHOR BOLT (2) *4 BAR CONT. FOUNDATION AND FLOOR FRAMING FLAN SCALE 1/4" = 1' -0" 2x RIM W/ 16d TOE -NAIL AT 4" 00 4" DIA. PERF. FND. DRAIN z K itWtW iFOR CODE COMPLIANCE APPROVED JAN 2 7 2009 City of Tukwila 2x4 P.T.1 I aNaDWISION W/ 3 "x3 "x1/4' GALV. PLATE WASHER AT 48" 00, MIN (2) PER SILL AND 12" FROM ENDS a 'of X 4 E ct ct RECE ;vFr DEC 3 0 2006 PERMIT CENTb. (3 \ NEW a FND WALL AND S "x1 6" FTG /2} SCALE 1" = 1' -O" Q O f m z `t U 0 LY • O L N z 0_ 0 0 u_ z 1- 0 0 .cNis SHEAR WALL DESIGNATION NAIL SIZE NAIL SPACING BLOCKING HENN - FIR *2 /FT EDGES STUDS TOP 4 BTM. PLATE NAILING P1 -6 Sd 6" 12" (2) 16d 6 10" YES 210 PI -4 Sd 4" 12" (2) 16d 9 1" YES 310 PI -3 Sd 3" 12" (2) I6d g 4" YES 400 P2 -3 Sd 3" 12" (2) 16d 9 3" YES 800 ' ( . 7 .$) I 6OOZ 'Si fiaenuer alt/CI 1 oo 'Si fiaenuer clasiA c1 I wVNIfTI rya altros OZ6t 109 90L NVNWO 2 )II1.4 Agl NmdIa i l FLOOR FLAN RO WIDTH RO HIGHT TYPE AREA MIN U -VAL 3 MAIN FLOOR ROOM COUNT RO WIDTH RO HIGHT TYPE AREA MIN U -VAL BED RM *2 1 4' -O" 3 SLIDER 14 sf 0.40 BED RM *3 I 4' -0" 3' -6" SLIDER 14 sf 0,40 TOTAL 2$.00 sf NOTES: 1 PI- 1/16 A.P.A. RATED PLYWOOD OR ORIENTATED STRAND BOARD ON ONE SIDE OF WALL P2- 1/16 A.P.A. RATED PLYWOOD OR ORIENTATED STRAND BOARD ON ONE SIDE. 2 FOR PI -3 AND P2 -3 SHEAR WALLS USE 3X STUDS OR (2) 2X STUDS NAILED TOGETHER PER SHEAR WALL PLAT NAILING AT ADJOINING PANEL EDGES AND MUDSILL NAILING SHALL BE STAGGERED. 3 WHERE PLYWOOD PANELS OCCUR ON BOTH SIDES OF THE WALL STAGGER JOINTS SO THEY FALL ON DIFFERENT $TUkl5 4 ALL PANEL EDGES BACKED WITH 2 -INCH NOMINAL OR WIDER FRAMING UNLESS NOTED. 5 INSTALL PANELS EITHER HORIZONTALLY OR VERTICALLY FOR PLYWOOD OR A.P.A. RATED SHEATHING. 6 SPACE NAILS AT 10 INCHES ON CENTER AT INTERMEDIATE SUPPORTS. SMOKE ALARMS SHEAR WALL SCHEDULE u I. IN EACH SLEEPING ROOM. 2. OUTSIDE EACH SEPARATE SLEEPING AREA IN THE IMMEDIATE VICINITY OF THE BEDROOMS. I.R.C. 8313.2 LOCATION. SMOKE ALARMS SHALL BE INSTALLED IN THE FOLLOWING LOCATIONS: 3. ON EACH ADDITIONAL STORY OF THE DWELLING, INCLUDING BASEMENTS BUT NOT INCLUDING CRAWL SPACES AND UNINHABITABLE ATTICS. IN DWELLINGS OR DWELLING UNITS WITH SPLIT LEVELS AND WITHOUT AN INTERVENING DOOR BETWEEN THE ADJACENT LEVELS, A SMOKE ALARM INSTALLED ON TI-4E UPPER LEVEL SHALL SUFFICE FOR THE ADJACENT LOWER LEVEL IS LESS THAN ONE FULL STORY BELLOW THE UPPER LEVEL. WHEN MORE THAN ONE SMOKE ALARM IS REQUIRED TO BE INSTALLED WITHIN AN INDIVIDUAL DWELLING UNIT THE ALARM DEVISE SHALL BE INTERCONNECTED IN SUCH A MANNER THAT THE ACTUATION OF ONE ALARM WILL ACTIyTE ALL OF THE ALARMS IN THE INDIVIDUAL UNIT. - "bec,roo w∎ G0%461.4).1 vAct/ 1h-ee -J �} t) \0"e. 1 1-1- VIAtS,5 Si ( iS tu'i4Wv\ 4 sIrow\ cvcde ou4 . ©fei h vvetc v b S, si. o k. 5 ∎ \,\ 'A-e A c 6 , 3- t M " o 1r �' e S$ ' moo w‘ e - eor4or 9 rActe `� pow 1Q.e &) Moon ✓ v■ ctiuvAA Vev Wl.�iOVA -{v_ TV' R,303.1 't hg i 4' -0" x 3' -6" BED RM #1 VERIFY ALL DIMENSIONS AND CONDITIONS AT JOS SITE EXISTING WALL WALL TO SE REMOVED NEW WALL SMOKE ALARM FLOOR PLAN SCALE 1/4 "= I -O" NORTH 8313.1 SMOKE DETECTION AND NOTIFICATION. ALL SMOKE ALARMS SHALL BE LISTED IN ACCORDANCE WITH UL 211 AND INSTALLED IN ACCORDANCE WITH THE PROVISIONS OF THIS CODE AND THE HOUSEHOLD FIRE WARNING EQUIPMENT PROVISIONS OF NFPA 12 HOUSEHOLD FIRE ALARM SYSTEM INSTALLED IN ACCORDANCE WITH NFPA 12 THAT INCLUDE SMOKE ALARMS, OR A COMBINATION OF SMOKE DETECTOR AND AUDIBLE NOTIFICATION DEVICE INSTALLED AS REQUIRED SY THIS SECTION FOR SMOKE ALARMS, SHALL BE PERMITTED. THE HOUSEHOLD FIRE ALARM SYSTEM SHALL PROVIDE THE SAME LEVEL OF SMOKE DETECTION AND ALARM AS REQUIRED BY THIS SECTION FOR SMOKE ALARMS IN THE EVENT THE FIRE ALARM PANEL 15 REMOVED OR THE SYSTEM 15 NOT CONNECTED TO A CENTRAL STATION 8313.2.1 ALTERATIONS,REPAIRS AND ADDITIONS. WHEN INTERIOR ALTERATIONS, REPAIRS OR ADDITIONS REQUIRING A PERMIT OCCUR, OR WHEN ONE OR MORE SLEEPING ROOMS ARE ADDED OR CREATED IN EXISTING DWELLINGS, THE INDIVIDUAL DWELLING UNIT SHALL SE PROVIDED WITH SMOKE ALARMS LOCATED AS REQUIRED FOR NEW DWELLINGS: THE SMOKE ALARMS ALARMS SHALL SE INTERCONNECTED AND HARD WIRED. EXCEPTIONS: 1. SMOKE ALARMS IN EXISTING AREAS SHALL NOT BE REQUIRED TO BE INTERCONNECTED AND HARP WIRED WHERE ALTERATIONS OR REPAIRS DO NOT RESULT IN THE REMOVAL OF INTERIOR WALL OR CEILING FINISHES EXPOSING THE STRUCTURE, UNLESS THERE 15 AN ATTIC, CRAWL SPACE, OR BASEMENT AVAILABLE WHICH COULD PROVIDE ACCESS FOR HARD WIRING AND INTERCONNECTION WITHOUT THE REMOVAL OF INTERIOR FINISHES. 2. WORK INVOLVING THE EXTERIOR SURFACES OF DWELLINGS, SUCH AS THE REPLACEMENT OF ROOFING OR SIDING, OR THE ADDITION OR REPLACEMENT OF WINDOWS OR DOORS, OR THE ADDITION QF A PORCH OR DECK, ARE EXEMPT FROM THE REQUIREMENTS OF THIS SECTION. N uTE..EartOEA WINDOWS 4' -0" x 3' -6" O -6" COMPUTER ROOM / STUDY EXISTING DOOR REMOVED -on 11 2/2 4' O" x 3' -6" NEW BED RM *2 ® 88.5 sq. ft. 3' -O" 3' -0" BED RM *4 BED RM *5 PI-6 EXIST 2' -6 "x36" WINDOW REMOVED LIVING RM EXISTING BATH —3 11 2' -6" 2' -0" SO C VKih r 3 -3%2" 25 -0 4' -0" x 3'4," \�I NEW BED RM *3 96 sq. ft. 6 -3" /\ .�� 5' -O" NEW L5[NIW R / �1, �hDVi Ut v� 1� h0 �'� 'e r 1 KITCI -IEN BATH BED RM *6 PI -6 L I Wit m x O ctl O cv r r LSTA36 AT TOP PLATE CODE CON; PUAM APPRCt'VED x JAN 2 2009 Qty : f Tukwila ECEWED 14 2009 PE" MIT CENTER Lif=fpER ROOF VENTILATION NOTE: ROOF VENTS ° COR —A —VENT (OR EQUIVALENT) RIDGE V -6OO -8 I /2 PROVIDES 20 5,1. PER 1.1. ROOF VENTILATION ROOF AREA: 300 s.f. VENTILATION REQUIRED: 300 s.f. x 144 SA. / 5.F. / 300 = 144 5.1. PROVIDE 1/2 VENTILATION AT EAVES, 1/2 ABOVE MIDPOINT 4 MIN. 3' ABOVE EAVE VENTS EAVE VENTILATION: BIRDBLOCKING 22 1/2" W/ (4) 2 I /2" DIA. SCREENED VENTS PER BIRDBLOCK = 15.63 8.1. PROVIDE MIN. (4) VENTED BLOCK'S VENTILATION PROVIDED: 18.52 9.1. RIDGE VENTILATION: PROVIDE MIN. 4 IS = 80 8,1, OR (2) 1 "xl ATTIC ROOF JACKS = 9S s.1. VENTILATION PROVIDED: MIN SO s.1. TOTAL VENTILATION REQUIRED: 144 5.1. TOTAL VENTILATION PROVIDED: EAVE 18.52 5.1. RIDGE MIN. SO s.i. 158.52 5.1. 1-41 AT EA TRUSS SECTION SCALE 3/4" = 1 -0 GABLE END TRUSS --\ A34 EA SIDE 2x6 BRACE SCALE 3/4" = 1 -0 A34 EA END TRUSS PER PLAN t LL (5) Sd INTO 2x SLK EA. SIDE OF BRACE (6) 16d EA SIDE SECTION NOTE: ONE BRACE AT CENTER OF WALL ° 4x8 *2 DF HDR MANUF TRUSSES AT 24" OC 4 :12 PITCH ( MATCH EXIST ) FIELD MEASURE EXISTING ROOT STRUCTURE BEFORE ORDERING TRUSS ii ROOF SHEATHING: 25 -0 ii I EXISTING ROOF PRE- MANUFACTURED ROOF TRUSSES: 4x8 *2 DF NDR PROVIDE MIN 22 "x 30" ATTIC ACCESS FROM EXIST TO NEW 2x6 1 AFTERS AT 24" OC ROOF FRAMING PLAN SCALE 1/4" = 1 -0 SHEATHING SHALL BE 7/16 /NCH AP. A. SHEATHING. SPAN RATING 32/16, INSTALLED W/TH LONG DIMENSION ACROSS SUPPORTS. PANEL END JOINTS SHALL OCCUR AT SUPPORTS. NAIL PANEL EDGES WITH Bd NAILS AT 4 INCHES ON CENTER AND 10 INCHES ON CENTER AT INTERMEDIATE SUPPORTS. INSTALL PLYWOOD CLIPS AT 443" ON CENTER LSTA36 AT TOP PLATE VERIFY ALL DIMENSIONS AND CONDITIONS AT JOB SITE iv'icvniu t OR CODE COMPLIANCE APPROVED JAN 27 2009 r ,.wo• B DiVI ALL TRUSS ENGINEER /NG DATA DESIGN DETAILS AND DRAW /NGS SHALL BE ON SITE FOR FRAMING INSPECTION. TRUSSES SHALL BE PLANT FABRICATED. TRUSSES SHALL BE DESIGNED BY AN ENGINEER LICENSED IN THE STATE OF WASHINGTON. TRUSSES SHALL BE DES /GNED IN ACCORDANCE WITH THE 'DESIGN SPECIFICATION FOR METAL PLATE CONNECTED WOOD TRUSSES, TP I': EACH TRUSS SHALL BEAR THE QUAL /TY CONTROL, STAMP OF THE MANUFACTURER. PROVIDE FOR SHAPES, BEAR /N6 POINTS, INTERSECTIONS, HIPS, VALLEYS ETC., SHOWN ON THE DRAWINGS. PRO VIDE ALL TRUSS TO TRUSS TO GIRDER TRUSS CONNECTION DETAILS AND REQUIRED CONNECTION MATERIALS. PROVIDE FOR ALL TEMPORARY AND PERMANENT TRUSS BR AC ING AND OR/DOING. ECEIVED DEC 3 0 2008 PERMIT CENTEF STRUCTURAL TIMBER: ALL GRADES SHALL CONFORM TO WWPA GRADING RULES FOR WESTERN LUMBER, LATEST EDITION. PROVIDE CUT WASHERS UNDER ALL NUTS AND BOLTS BEARING AGAINST WOOD. ALL WOOD IN CONTACT WITH CONCRETE SHALL BE PRESSURE TREATED IN CONFORMANCE WITH SECTION R319.1. ALL STRUCTURAL LUMBER SHALL BE NOTED BELOW 2X FLOOR $ ROOF JOIST 4X BEAMS 6X BEAMS COLUMNS LUMBER NOT NOTED HEM- F /R- - - - - -- Fb = 850 P51 DOUG -FIR /LARCH "2 Fb = 850 P51 DOUG -FIR /LARCH *2 - Fb = 850 P. / DOUG -FIR /LARCH *2 Fb = 850 PSI DOUG - FIR /LARCH +M2 Fb = 850 P51 MISCELLANEOUS HANGERS TO BE SIMPSON OR APPROVED EQUAL. ALL HANGERS SHALL BE FASTENED TO WOOD WITH PROPER NAILS. ALL HOLES SHALL BE NAILED. MACHINE BOLTS TO BE A-307. ANCHOR BOLTS INTO CONCRETE SHALL BE 5/8 INCH DIAMETER WITH 7 /NCH EMBEDMENT INTO CONCRETE UNLESS NOTED OTHERWISE ON THE PLANS_ ALL NAILS SHALL BE COMMON WIRE NAILS. NA /LING SHALL CONFORM WITH I.R.C. TABLE R602.3(22 FASTENERS INSTALLED IN PRESERVATIVE TREATED WOOD SHALL BE HOT DIPPED GALVANIZED PER I.R.C. SECTION R319.3. EXCEPTION: ONE- HALF-INCH DIAMETER OR GREATER STEEL BOLTS. FLOOR SHEATHING: SHEATHING SHALL BE 3/4 /NCH TONGUE 1 GROVE, A.P.A. RATED SHEATHING. SPAN RATING 48/24 WITH LONG DIMENSION PERPENDICULAR TO SUPPORTS. UNLESS NOTED OTHERWISE WITH 8d COMMON NAILS AT 6 INCHES ON CENTER AT SUPPORTED PANEL EDGES J /0 INCHES ON CENTER AT INTERMEDIATE SUPPORTS. THE FLOOR SHEATHING SHALL GLUED TO THE JOIST WITH AN APPROVED ADHESIVE. WALL SHEATHING: SHEATH ING SHALL BE 7/16 /NCH A.P.A. RATED SHEATHING, SPAN RATING 24/0. PANEL END JOINTS SHALL OCCUR AT SUPPORTS. NAIL PANEL EDGES WITH 5d NAILS AT 6 INCHES ON CENTER AND 10 INCHES ON CENTER AT INTERMEDIATE SUPPORTS UNLESS NOTED OTHERWISE ON THE DRAWINGS FLOOR FRAMING: PROVIDE FULL DEPTH BLOCK ING FOR JOIST AT THE SUPPORTS. FLUSH BEAMS (F) AND HEADERS NOT CALLED OUT ON THE PLANS SHALL BE 2X10. ALL VERTICALLY LAMINATED BEAMS AND HEADERS SHALL BE SPIKED TOGETHER WITH 16c/ NA /LS AT b INCHES ON CENTER. BEARING WALL FRAMING: ALL DOOR AND WINDOW HEADERS NOT CALLED OUT ON THE PLANS SHALL BE 4X8 "2 DOUGLAS -FIR WITH ONE CRIPPLE AND ONE STUD EACH END FOR OPEN /NGS 4 Fkk/ OR LESS AND 77110 CRIPPLES AND ONE STUD FOR OPENINGS MORE THAN 4 FEET WIDE. ALL COLUMNS NOT CALLED OUT ON THE PLANS SHALL BE (2) STUDS. SPIKE LAM / NOTED COLUMNS TOGETHER WITH 16d NAILS AT /2 INCHES ON CENTER. PROVIDE TWO LAYERS OF ASPHALT IMPREGNATED BUILDING PAPER AT CONTACT SURFACES BETWEEN WOOD AND CONCRETE. WALLS SHALL HAVE A SINGLE BOTTOM PLATE AND A DOUBLE TOP PLATE. END NAIL TOP AND BOTTOM PLATES TO EACH STUD WITH (2) /6d NAILS. FACE NAIL DOUBLE TOP PLATES WITH 16d AT 10 INCHES ON CENTER. LAP AND FACE NAIL PLATES WITH (2) 16d NAILS AT EACH SPLICE, CORNER INTERSECTION. STAGGER SPLICES A MINIMUM OF 48 INCHES. FACE NAIL BOTTOM PLAT TO WITH (2) lbd NAILS INTERIOR WALL - 2x4 STUDS AT - 1/2" GWS EA 5 \ 5/ ASSEMBLY 16" OC DE SCALE 3/4" = 1' -0" EXISTING WALL SHEATHING LEFT IN PLACE (RE -NAIL TO PI -6) MID MD OM Ohl N ' iitititititititititititiontitaitiontaiir 'bt BUILDING SECTION !„,„„) SCALE 1/4" = V-0" MIN 1" AIR 5PACE C ris WALL SECTION NEW ROOF ASSEMBLY EXISTING - 3 -TAB ON 15" FELT. MATCH EXISTING - ROOF SHEATHING: 1/16" A.P.A. RATED, SPAN RATING 32/16, NAIL PANEL EDGES W/ ad AT 4" OC AND 10" AT INTERMEDIATE SUPPORTS.PLYWOOD CLIPS AT 48" OC - PRE- MANUFACTURED ROOF TRUSSES AT 24" OC - INSUL MIN. R -38 - INTERIOR FINISH 1/2" GWB VENTED BLOCKING SEE ROOF VENTIATIO• SHT. 4/6 EXTERIOR WALL ASSEMBLY - 10" HARDI PLANK OVER HOUSE WRAP - 2x6 STUDS AT 16" OC - INSUL R -21 - INTERIOR FINISH 1/2" GLIB FLOOR ASSEMBLY - FLOOR SHEATHING: 3/4" T4G A.P.A. RATED SHT., SPAN RATING 48/24. NAIL W/ ad AT PANEL EDGES AND 10" OC AT INTERMEDIATE SUPORTS. FLOOR 51-IT. SHALL BE GLUED TO THE JOIST W/ AN APPROVED ADHESIVE. - 2x10 *2 HEM -FIR F/J AT 16" OC - INSUL MIN R -30. FOUNDATION SEE FOOTING DRAIN v1 vVtU �oR CODE COMPLIANCE APPROVED JAN 2 7 2009 City Of Tukwila _BUILDING DIVIS ECEIVED OTC 3 0 2008 PERMIT CENTER SOUTH ELEVATION SCALE 1/4" = 1 -0" SCALE 1/4" = 1 —O" WEST ELEVATION X 23 NORTH ELEVATION SCALE 1/4" = 1 —O" CODE COMPLIANCE APPROVED JAN 2 , 7 2009 • Oty0fTukwila JUILDINGIVI ION RECEIVED DEC 3 0 2008 PERMIT CENT& Q w d) } w oc w 4 U z O 1- 4 1 is 4 1- 0 U