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HUNTINGTON BEACF
CERTIFICATE OF OCCUPANCY _ttw -
CITY OF HUNTINGTON BEACH —
Business Address f `'C,i
Business Owners Name
Business Name �0
Business Type M�1
DEPT. OF COMMUNITY DEVELOPMENT APPLICATION
(3'd Floor - The ApplicantMustApply In -Person)
26o w 13 C ! Date T -�
ow�✓to�c-l. Zip Code 5
Sc•— s UT,S�F Telephone No. 37 f !L&A - �ca
't t�sey` Bus. Phone �Lf 9(,(-7.-0
Property T Owner Information (required) _ enant/Emergency�,ta (�required)
Name UL-C, Name
Address Or ✓ Home Address
City State/ ip CA- 902 j' City State/Zip
Telephone No. .3 to ZG_r-i /51 Telephone No.
THIS USE WOULD BE DESCRIBED AS:
O Newly Constructed Building or ;XExisting Building
IS THIS BUILDING FIRE SPRINKLERED? 9 Yes []No
CHECK ALL THAT APPLY:
❑ Change of Business Owner XChange of Occupant ❑ Change of Use ❑ Additional Occupant
■ Indicate former type of business
■ Are you requesting that the electricity be turned on? ❑Yes XNo
■ Will operations produce dust/wood shavings or similar material? ❑ Yes ANo
■ Will operations involve the repair or replacement of automobile parts? ❑Yes Zo If yes: Describe the
components repaired or replaced.
■ Does the operation involve the use of welding or open flame? ❑ Yes 9k No
■ Will the business be a drinking, dining or assembly use with an occupant load of more than 50 persons?
❑ Yes 5TNo
■ Will there be storage racks, gondolas, or shelving exceeding 5feet 9 inches in height? ❑Yes JKNo
■ The following best describes my operation: ❑ Office Only ❑ Retail Sales ❑Medical/Dental
Warehouse /Manufacturing/Distribution ❑ Restaurant/Take-Out Food ❑ Other
■ Will any meat products including beef, poultry, and/or fish bee cooked or fried onsite? ❑ Yes X No
If you answered yes, please proceed to the next question.
• Does your facility currently have a grease control device (i.e. grease trap or grease interceptor)?
Check one: ❑ Yes )4 No
For Official Use Only -�
Occ Group:
Occ Group:
Occ Group:
Total Sq Ft Occupied: p?
Bldg. Permit #
Planning Initials:, Date: l
11
Conditions of Approval or Other Notes:
Area: P l IF & 3
Area:
Area:
No. of Storis:_
Entitlement #:
Occ Load: 60
Occ Load: / Q y
Occ Load:
TIF Review: Y/
Zoning:
Building Reviewed By Initials: Date:
Grease Interceptor Verified Inspected By Initials: Date:
South Coast
Air Quality Management District
` 21865 Copley Drive, Diamond Bar, CA 91765-4182
(909) 396-3529 • http:// www.agmd.gov
Air Quality Permit Checklist
California State Law Code 65850.2 prohibits cities from issuing an occupancy permit to a
business without clearance from the local air quality agency. This checklist will determine if you
need to obtain clearance from the South Coast Air Quality Management District (AQMD).
Company Name:
Property Address: 64A-C--
City:4w4m;�_1 stla� Zip Code: L9�_ USK
Contact Person: a A W1I-L Title: E H S heC444
Type of Business: manti a n Telephone: *1l4'. 3W L 1 1�
Fax Number: e-mail address: NO . aw @It
�odi� caewy�C�e G
Applicant (print name): RIP Signatu : Date:
• Will the facility have any of the following equip m n s ❑ No�
Charbroiler /
Dry cleaning machine
Spray booth
Printing press (screen/lithographic/flexographic)
Internal combustion engine greater than 50 HP (excluding motor vehicles)
Boiler/combustion equipment (greater than 1 million BTU/hr. maximum input)
Abrasive blasting cabinet/room
Baghouse/cartridge-type dust filter/scrubber
Motor fuel storage and dispensing equipment
• Will any of the following operations be performed? Yes❑ N'o6
Application of paints or adhesives
Etching, plating, casting, or melting of metals
Molding, extruding, or curing of plastics
Mixing and blending of liquids and/or powders
Storage of acids, solvents, organic liquids, or fuels
Production of fumes, dust, smoke, or strong odors
If you answered "No" to both questions, this checklist is your clearance from AQMD. If
you answered "Yes" to either question, you must contact AQMD to determine if air quality
permits are required. If permits are needed, AQMD will assist you in submitting permit
application(s) and then provide you with a clearance letter. You can call AQMD at their Small
Business Assistance Office at 1-800-CUT-SMOG (1-800-288-7664).
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