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APPLICATION FOR C_vRTIFICA TE OF' SS&EANCY
CITY OF IHUNTINGTON SEA 4 r
DEPARTMENT OF COMMUNITY DEVELOPMENT
HUNMCIT 1N BFMY (PRINT OR TYPE ONLY) DATE
� C) `�
Address - t I S u �,-"i 1.0 �-�—E�-�=�� District
Business Name ' ' ` t 1`� F' 4' 2� -r m C T f= (_ Tel.
Pusiness Type Occ. Group"
BUILDING OWNER BUSINESS OWNIERt' MANAGER
Name-Q %)- I x:iv Suitt" (�, R Name Q 0 1— t A _
Horne' i' /
Addressi'ts t (fib S+v ` Address?t v —' ` j
City��C Tei City � §�� Home Tel,
THIS USE: WOULD BE DESCRIBED AS:
NEWLY CONSTRUCTED BLDG. CHANGE OF OWNER ❑ CHANGE OF OCCUPANT
EXISTING BUILDING ❑ CHANGE OF 'JSC ❑ ADDITIONAL OCCUPANT
Indicate former use, ii any t >- Occupancy Gr Civ
} SQUARE FT. OF BUILDING TO BE OCCUPIED>�D
NOTICE:: 1, , occupancy of any building is prohibited and a business license will not be issued until the building has been
Inspected and a certificate of occupancy is issued.
2. No electrical service will be released for any existing building until the service has been inspected and
certified safe. All applicants for occupancy in an existing building are reg2jiruu }� icneuule an electrical
'fuse up' inspection in the Department of Community Development at the time this application is filed,
3, Change of occupancy or use inspection fee, Whenever it is neco-sary to snake inspection of a building or
prerrf ses in order to determine if a change may be made in the character of occupancy or use of the building
i or premises which would place the building in a different division of the s7me soup of occupancy or in a
i different group of occupancy, a change of occupancy ins pection fee of $ shall
be paid to the city.
4. Huntington Beach Fire Code Section 10.208 requires that building numbers must be a minimum of four(4)
inches in height with one half ('/z) inch stroke, and of a contrasting rolor from the background. These
t numbers must be posted on your building in a location that is visible from the street.
a 5. Huntin-;ton "'. 4ch Fire Code Section 10.301 requires fire extinguisher selection and distribution per the
? National Fire Protection, Association pamphlet 10 (see reverse side).
TRP FFIC IMPACT FED t �DATE PAID r
AMOUNT R,rC f''NED
" (FOR OFFICE USE ONLY)
NAt1i ��ryry ZONING
OCCUPANCY GROUP__-=► PLAN CHECK NO NO PARKING SPACES
OCCUPANT LOAD a - PERMIT NO HEALTH DEPT APPROVAL,
1
NO. OF STORIES ADMIN, ACTION UTILITIES RELEASED
'�- CERTIFICATE OF OCCUPANCY FEE $
APPV
' CHANGE OF USE OR OCCUPANCY FEE, $
3' E��l�
t TOTAL $
z6.03s ReV.1/97 COM�1l1NITY DEVELOFM561T
SUPPLEMENTAL INFORMATION
1.
BUSINESSADDRESS
2.
Person to ,,ontact " in case of emergency �{ f
i elephone number:
G'- &,4/ _ _ VO -S GAS
3.
Does the; building in question have electricity?
,ET -Yes
❑ No
`(a) If No, are you requesting that the eleciricity be
❑ Yes
turned on?
❑ No
' 4.
The building is sprinklered?
❑ Yes
-No
5.
Operations will ` produce dust/wood shavings`, or sirrrilar
material?
❑ Yes
0-'No
6.
Operations will involve the repair or rel lacement of
❑ Yes
automobile parts?laa
If Yes:
(a) Describe the cot-noonents repaired or replaced,
❑ Yes
(b) Does the ` operation involve the use of an open flame?
No
7.
The `business is winking dining or assembly use that will.
result in an occupant load of more than 50 persons.
❑ Yes
TNQ
8.
The following best describes my operation;
Office Only
Retail Sales
Warehouse
Manufacturing / Distribution (describe process and end product)
Restaurant / Take Out Food
Medical / Dental
Other (describe)
SUPPLEMENTAL INFORMATION
SUPPLEMENTAL, €NPOR AT'i0N,
(Continued)
Does
the operation involve :any of the following materialsT, ❑ Yes
❑ No
If
Yes, indicate quantities:
Material Quantity
I.
Flammabls ; liquids
Class I -A
Class 1-13✓
Class I -Cry
2.
.Combustible liquids
Crass ll
1�
Class f l l-A
J
3.
Combination flammable liquids,
4.
Flammable gases
5.
Liquefied flammable gases
6.
Flammable fibers - loose
7.
Flammable fibers baled
8.
Flammable solids
9.
Unstable materials
CJ
10.
Corrosive liquids.�i)
11,
Oxidizing material'- gases
12.
Oxidizing material liquids
13�
Oxidizing material - solids
1".
Uiganio� peroxides
15,
Nitrornethane (unstable materials)
-
MID
16.
Ammonium nitrate
17.
Ammonium nitrate c,ompouxnd mixtures
containing more than 60% nitrate
by weight
18.
Highly toxic material and
�
poisonous gas
19.
Smokeless powder
20.
Mack sporting pow,ler
I hereby certify that the aaove information is true and .correct ` to
the best of my knowledge,
,�:.' �Signatur� `��
Date
South Coast
AIR. QUALITY MANAGEMENT DISTRICT
21865 E. Copley Drive, Diamond Bar, CA 91765-4182 (909) 396-2000
s
AM QUALITY PEST CHECKLIST
for nonresidential buildings only
Company Name; _ GG? fir{' c e 1` t I 4
Location ofPr9p( ty: zz r 53
City: ',�' -�. --r. - 1877C r9 c �' Zip Code: G r
Contact Person: 4Al Title: c�
Telephcire Number: 7� 1i yf
Type of Industry/Business:
To apply for a nonresidential building permit, you must complete this checklist. If you have any
questions shout completing this checklist, please call (800) 38E-2121.
YES NO
1. Will the facility have a charbroiler? [ ]'
2. Will any internal combustion engine with greater than Sit horsepower E
operate at the facility (excluding motor vehicles)? [ ] [
3. Will operations at the facility involve mixing, blending, or processing of
solvents, adhesives, paints or coatings? [ ] {
4. gill dust or smoke be generated at the facility? { ] [
5. Will refuting of any liquids or solids be done at the facility?
6. Will any plating or coating of materials be done at the facility?
7. Will any combustion equipment rated greater than 2,000,000'PTUT/hr oe
operated at the facility?
8. Will any acids, solvents, or motor fuel be used or stored at the facility? [ ] { 4
9, Will any organic liquids or gases be reacted or produced? [ ] N1
10. Will any ovens be used to dry, or cure products at the facility?
11. Will any CFC (Freon) recycling machines operate at the facility? [ ] []
Applicant:.L��� Signa�re:
(Print name clearly)
If you have mar'Aed "NO" in all the boxes, an air quality permit is IIgt needed at this time,
and this checklist is your written release.
If you marked "YES" in any of the boxes, you must contact the South Coast Air Quality
Management District (AQMD). Please read the reulArements on the back of the checklist.
(800) 388-2121
u
ADDITIONAL SUPPLEMENTAL INFORMATION