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APPLICATION FOR LARGE FAMILY DAY CARE PERMIT Planning Division Case No.: 38250 Sierra Highway Palmdale, CA 93550 Date: (661) 267-5200 [EMAIL REDACTED] Received by: Fee: $158 (Renewal fee is $79) Request to conduct a LARGE FAMILY DAY CARE facility located at: Street Address Will there be employees other than the applicant? Yes / No How many? Outdoor fenced area in square feet: Indoor area in square feet: List any other day care facilities located within 300 feet of proposed location and give addresses: NOTE: A Large Family Day Care facility may not be located within 300 feet of another Large Family Day Care facility. This permit may be denied should there be a permitted and licensed facility within 300 feet of the applicant. PROPERTY OWNER: Name and Email Address: Address, City, State, Zip: Telephone No.: ( ) Fax No.: ( ) APPLICANT: Name and Email Address: Address, City, State, Zip: Telephone No.: ( ) Fax No.: ( ) CA Drivers License No./ID Number: If the property owner and the applicant are different, the attached authorization from the property owner must accompany this application. I have read and understand the Conditions of Approval listed on Page 4 of this application. Applicant Signature: Date: Updated 1/20 ---PAGE BREAK--- INSTRUCTIONS TO APPLICANT This application form is provided for all persons who propose to file a request to establish a LARGE FAMILY DAY CARE* facility in the City of Palmdale. The applicant must complete the front page of this form as prescribed, incorporate all requested information and the fees paid before the application can be accepted for processing by the Planning Division. Applications that include project plans may be submitted via email to: [EMAIL REDACTED]. Prepare a site plan of the facility. This site plan may be based on the indoor and outdoor facility sketch provided to the State of California, Department of Social Services, modified as necessary to include the following: 1. Structures - location on lot, distances between structures and property lines and use of existing and proposed structures. Include structures such as sheds, swimming pools and play equipment in addition to the primary residence/garage. 2. Fences and Walls - location, height and composition of all existing and proposed walls, fences, and retaining walls. 3. Circulation/Parking - all driveways, walkways, and parking areas. Identify designated child “drop-off/pick-up” areas. SUBMITTAL CHECKLIST Completed Application Copy of State of California Department of Social Services Family Day Care License The original Owner’s Authorization Letter (if applicable) One copy of the Site Plan. Site plan may be a copy of the indoor and outdoor facility sketch provided to the State of California, Department of Social Services. Site Plan to include the above-referenced criteria. PLANS MAY BE PROVIDED ON 8½” x 11” or 11” X 17” SIZE PAPER. If you have any questions regarding this application packet, required documents, and materials or Palmdale Municipal Code requirements for day care centers, please call the City Planning Division at (661) 267-5200. *A Large Family Day Care Facility is defined as a single family residential facility, occupied by the operator, which is licensed and utilized for the purpose of providing daily non-medical care and supervision of seven to 12 children under 18 years of age, plus up to two additional school age children as permitted by the State Department of Social Services. ---PAGE BREAK--- OWNER AUTHORIZATION LETTER ADMINISTRATIVE APPROVAL APPLICATIONS CASE NUMBER(S): ASSESSOR’S PARCEL NUMBER(S): If the applicant is not the owner of record, then a letter authorizing the applicant to represent the owner(s) must be submitted. Note: All owners must sign as their names appear on the deed to the land. This letter shall serve to notify and verify that I/we am/are the legal owners of the property described and attached hereto and do hereby authorize the applicant to file and represent my/our interest in the above referenced applications(s). I/we have read this Letter of Authorization and know the contents thereof; and so hereby certify (or declare) under penalty of perjury under the laws of the State of California that the information contained in the above referenced application(s) is true and correct. OWNER(S) OF RECORD (Include extra sheets if necessary): Printed Name Signature Date Printed Name Signature Date I certify under penalty of perjury that I am the applicant and that the foregoing statements and answers herein contained and the information herein submitted, are in all respects true and correct. APPLICANT / APPLICANT’S REPRESENTATIVE: Printed Name Signature Date Address Telephone Printed Name Signature Date Address Telephone Printed Name Signature Date Address Telephone ---PAGE BREAK--- THIS PAGE WAS INTENTIONALLY LEFT BLANK ---PAGE BREAK--- CONDITIONS OF APPROVAL FOR LARGE FAMILY DAY CARE PERMIT 1. This facility must be re-inspected annually. A re-inspection fee of $89 must be paid upon receipt of notice from the City. This fee may change subject to the annual approval of a Fee Resolution by the City Council. 2. Applicant must obtain all necessary permits from the State and maintain compliance with the requirements of those permits, as well as all applicable State and local building, fire and health codes. If such permits are revoked or denied or you do not comply with State and local codes, this approval will no longer be valid. 3. The resident’s vehicles shall be parked in the garage during the hours the day care service is operated, any employees coming to the residence to assist in the day care operation shall be provided with a parking space in the garage or driveway, and one parking space in the driveway for pick-up and drop-off of children shall be provided. 4. Adequate area shall be available for a drop-off and pick-up zone for parents, so as to avoid any adverse traffic or parking impacts to the residential neighborhood. If traffic generated from the day care use results in a negative impact to the neighborhood, this Permit can be revoked. 5. The garage shall not be used for day care purposes. 6. The facility may only be operated within a single-family dwelling unit having sufficient indoor and outdoor area to meet state and county requirement, including a fenced play area. 7. No more than 14 children may be supervised at the day care facility at any given time, including children who reside at the home. 8. No signs advertising the day care service shall be allowed, either on or off the premises. 9. The subject dwelling shall not be altered, furnished, or decorated for the purpose of conducting the day care use in such a manner as to change the residential character and appearance of the dwelling. 10. There shall be no entrance or exit specifically marked on the dwelling or on the premises for the conduct of the day care use. 11. Outdoor play areas along common property lines with residential uses shall be screened with not less than a six foot high fence, wall, or hedge, which provides for sound attenuation. 12. Any reasonable condition, imposed by the reviewing authority, deemed necessary to protect public health, safety, and welfare (Section 26.01.B). 13. Upon request, the City may inspect the premises to verify compliance with all City codes and ordinances.