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APPLICATION FOR CERTIFICATE OF OCCUPANCY
CITY OF HUNTINGTON BEACH
DEPARTMENT OF COMMUNITY DEVELOPMENT
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THIS USE WOULD BE DESCRIBED AS:
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NOTICE: I or Id
�(;Up3f,Gy of building is prolubotedand a b0inesslicenso will not be until the building
inspected and a ceflikate Of OCCUPsInG4 is issued
2 No electrical Service 00111 be fGIOW"Od for any existing building tintil the service has been inspected and
cert,fie.:j rile. Ali appl%antll for OCCUP3111GY in an existing building art. required to Gehedule an electrical
j jon is filed
(;,;e jjp r,�Tipv ciron in the De-pattment Of *ofnirn�jr, (, ity Development at Me time this application
3 Change of occupancy or use inspection fee. Wherjoy(,q it 15 rte.zrl';5;3ry to make infpectiOn of tmilding or
order to delectnine if f,h,lvqr ruay be made in the charm ter ofmcupam;yor use of If.0 building
wjjt, tj vjfu,(ej plap,t! the buijuq irl i dcl
Meterd .vv3iml (it Ile 4-ic-ityre!)roupoIoccupancy oriiiii
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ri, group (;j fjijupai,#�y� a fbangl) of uftcupil CYnspoc
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bf� P'"lid, to lf:e (Ginty
4 Huntington Beach Fire, Code Section 10 208 requiref) that building nurry
nbrlm must be a "nifflUm of four (4)
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itj,,�iriei in heqki! onf, ty,,jit t,,.j inchsltolie. and of jj conjijraiq rolor frfirn tho Darkt yound Those
nimberS niu,,;t be pfcsled nn your building in a location that j5 iij!pble, from tht, qlrcot
5 Huntington Beach Fire Code Section 10 391 requirps fire extinguisher stilmhon and diqtribution por the
Nali(,nal Fife Protection Asjowat;on pamotill't 10 Nee feveme. mdo)
(FOR OFFICE USE ONLY) �v� ��%� �
SUPPLEMENTAL INFORMATION..,
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SUPPLEMENTAL INFORMATION
1. BOSINESS ADDRESS r '• �; r;:^�,,, r�, .y �l _
z. Persorf to contact in case of emergency;'`
Telephone number:
3. Does the building in gtiestion have electricity? ONas
a. If No, are you requesting that the electricity he Oyes
turned on? ONO
4. The building is sprinklered? Byes
ONO
. operations will produce dust/wood shavings Or similar Oyes
material? QNo
6, operations will involve the repair or replacement of OYees
automobile parts?
If yes: 1 d
(a) Describe the components repaired or rep %CO
(b) Does the operation involve the use of, 6n n flaw!? Nos
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7. The business is drinking, dining or assembly ua4 that Will
,result in an occupant load of more than 50 personal. MYes
8. The bes describes my operations
(-Pf fice only
Retail."Saleb
Warehouse
Manufacturing/vistribution (describe procvss and end
product)
estauran a e Out PoodO
Medical/Dental,
Othfr (describe)_...
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SUPPLEMENTAL INFORMATION (Continued)
Does the operation involve any of the following materials? OY�ees
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es, xn 1ca a quant,ties:
Material quantity
1. Flammable liquids
Class I -A
class I-S
r1ass I-C
2. Combustible liquids
Clasa II — „ -
-�_� Glass 1I1 -A
.�3 Combination flammable liquids -
�4 Flammable gases
5. Liquefied flammable gases
6. Flammable fibers loose
7. Flammable fibers - baled
8. Flammable solids
9. UnsFable materials
10 Corrosive lig ds
11 Oxidizing material Gases __.
12. oxidizing material - liquids
13 Oxidizing material r solids
14 Drganic peroxides
15. t�itromethune (unstable materials)
16 Ammonium nitrat,�,
17. Ammonium nitrate compound mixtures
containing more than 60% nitrate
by weight
18, H;ryisly toxic material and
�poissonous gas
19. Sdokeleas powder
20. slacK_g2ortin5 powder
I hereby certify that the above information is true and correct to the
best of my„knowledge.
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Signature Dat
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SOUTH COAST AIR QUALITY MANAGDIENT DISTRICT
(Nonresidential Buildings only)
1,ocatiori of Subject Property;
Property owner name: Phone
Name of the person Preparing this form in print and signature
Name signature.t
wz,,the person preparing this form must be the same person applying for
building permits. Please answer the following questions regarding your
proposed occupancy of the 5ubje building. IF YOU DO NOT KNOW THE ANSWER
TO A QUESTION HARK IN THE 11YE LUMN:
S--AQmD PERMITTING CHECKLIST
YES No
1. Does your facility use any internal combustion
engines greater than 50-HP? _Z_J
2. Does your facility involve mixing, blending, or
prv-using any solvents, adhesives, Paints
or ,-oatings?
3. Does your facility create any dusts or smoke? 4. Does your facility refine any liquids or solids?
Reclaim any metals?
5. Does your facility Plate Or coat anything?
U. Does your facility have any combustion equipment
i.e. Nailer, furnaces, broiler, baking ovens, etc.)
rated greater than 2,000,000 BTU/HR?
7. Does your facility handle or store solvents or motor
fuel?
8. Do you use or store any acids? rT7_1
S. Do you use any chamica! process?
10. Do you Use any solvents for clean-up?
11* Are you a dry cleaner, restaurant with a charbroiler,
body shop, gasoline station, printer, or part coater?
12. is the subject building located within one thousand
(1,000) fee4s of any school?
PROPERTY LINE TO PROPERTY LINE. GRADES K-12.
If you have marked "Not' in all columns, you do not need an Air Quality
permit at this time. if you have marked any questions in the "YES" Column
you must contact the south Coast Air Quality Management District located
at: 9150 FLAIR DRIVE, EL MONTE, CA 91731
Please call these offi!::est Plan Check (818) 572-6406
(818) 572-6111, (8!8) 572-6261
D:AL00603
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