HomeMy WebLinkAbout15021 GOLDEN WEST - CofOSUPPLEMENTAL °tNE0APAI1T10N
.
1.
BUSINESS ADDRESS
2.
Person to Cori#act ' in case of emergency, to r= C,w�,
Telephone, number:-��
3.
Does, the building in question` have electricity?
2Yes
{a) If No, are .you'' requesting that the electricity be
❑ No
; C3 Yes
"
turned on?
C7 Nv
a
4.
The building is aprinkleredT
❑Yes
❑ No.
dperatiohs will produce dust / wood shavings or similar
,materia-0
CiY�7,es
fi.
Qpet`ativns will, `involve the repair or replacement of
❑ Yes
ti
i
automobile. 'parts?No
J
if •Yes:
: (a). , . Describe the components. ` repaired or replaced.
Ji
g t,.
() C)oes the opbration involve the use of an open flame?
❑ Yes
i ..
°LKN o
Tlhe business is drinking, dining or assembly use that ,wil=.-
result in an oceupantT load of more' than 50 persons.
❑Yes "
8.
The foflowing test describes my operation
w.
Office. Only
f1etaal:, Sal
fe;
ct ` / Distribiatio
g a describe process and end product)
Restaurant f Take aut " Food
Medical 1 Dental
rt
tither' (describe)
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e
SUPPLEMENTAL iNFORMATI N
t'
South C� .t
AIR QUALITY MANAGEMENT DISTRICT
21865 E. Copley Driver Diamond Bat, CA 91785-4182 (909) 396-2000
AIR QUALITY PERMIT CHECKLIST
for nonresidential buildings only
&
Company Narn6. C'OA S T'r ,C. V
Location of PropertyCat
ci f • � z1P coa — -_
4,
,
:Cantac ,Person: �5'K�ti Title: ,^
Telcphon Nlmbei :. Fax Number:
Type of Industry/Busiiress:
to ap'ply.for anoriresid�ent at building permit, yotimust complete this cuec% ist. If have any
i
questions about completing this checklist, please call (800) 3 88-2121
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YES
I, Willthe facility have:a charbroiler? (I
NO
-
2� : Wxll:any internalcombustion engine with greater than 50 horsepower
<
,' *operate, at.the, facility .(excluding, motor ;, rehiclesj?
Will operations rit the facility involve miring, blending, or processing of
f
solvents, adhesives, paints,or coat%ngs?
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4.. Will dust or smoke be,gentrated .at the facility? [ a
C
5:P Will refining of any liquids or solids be done at the facility?
6. Will any platurg pr coating of materials be done at the facility? [
[ .
7� Will any coanbur'� ion equipment rated greater than 2,000,Q00 BTU/hr be
the+facility?
.operated at l
R< ill any acids, solvents, or motor fuel be used or stored at the facility!,
9. Will any organist, lirTmas or gases be reacted or produced?
10. Wi1F any, ovens be used to dry or cure products at the facility?
11. Will any CFC (Freon) recycling machuies operate at the fa ' ity?
Applicant: 1 is G- t '' i t �f ri.v Signa'
6' e:,
(Print name clearly) '
Tfyou have marked "NO" in !1 the boxes; an air duality permit is not needed at this time,
and this checklist is your written release.
Ifyoumarked '°YES" in any of the boxes; you must contact the South Coast Air Quality`
Managerikent District (AQMD). Please read the requirements on the back of the checklist:
(800) 388:2121
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ADDPTiONAL SUPPLE'S NTAL INFOPMATION
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APPLICATION FOR CERTII{ICATE OF OCCUPANCY
CITY OF HUNTINGTON BEACH DEPARTMENT OF BUILDING & SAFETY
(3rd Floor _ Nfttst tl pp/3r In-I'(,rsott)
Business I,ic--nsc 4Date
,Address \Soak ��t�,�hu..�s� _t � C� c.r� `��.6`7?
Business l,�tame -rv\ e e-�s-t- r\ H % !j. C,� ft- r _ Telephone too '
Business Type
i eT*�etn act Information Business Owner
Name 51,rn�r5 r ",ti�4b Name
Address tq�+!wt.n!n: to a .home 1
City co '601) o Tel.. Cit i
THIS U 'E WOULD 13E DESCRIBED AS:
❑Nevvly Constructed Building car l;xfstitag Bu l
CHEC L.L THAT APPLY:
71eromlaelrl
hge of Owner Change of Occupant ❑C'r
Indiuse, ifala
s I)(aes the building have electricity? Yeses- NoC]
IfNm, are You requesting that the electricity be turned on. `l
The building is sprinklered? Yes Q No
t Operations wvill product dust'wood shavings or similar materia
Operations Will im°olN e dierepair or replacement of automobi'
If Yes: Describe the components repaired or replaced.
Does the operation involve the use of Welding or open flame?'
Thebusiness is drinking, dining or assemble' use that will resu
of more than aft persons. Yes ❑ No
The following best describes nay operation:
❑Ofl"sec Only URetail,Sales ❑MedicalMental ❑I2
❑iN4anufaeturinct'Distribtit on (describe process and end prod.....,
❑ Other (describe)
APPLICATION FOR CERTIFICATE OF OCCUPANCY
CITY OF HUNTINGTON BEACH - DEPARTMENT OF t3UILDING & SAFETY'
(3r,r Floor - Must Apply fi:-Person)
Business License # Date,_��"7
Address �; o2L G� e�slcl_ -} 1'} C� <- C+ 9.2-6`1
Business Name T�N e 4 o i F- co,-ts-y- o�z% Htvic w §��. s Telephone `/t`j is`SOO
Business Type
t+mMffact Information Business Owner
f Address to w Home Address 1.� City vx9 Grp 5sc%ir c2"Tel. pity; } Tel. '7-�t?t' 7�
THIS U 'P VN'OULD BE DESCRIBED AS:
❑Newly Constructed Building or aralsting Building
CHEC ' Ll, THAT APPLY-
rj
G
'haOwner change of Occupant Change of tise ❑Additional Occupant
Indica e formnge of er use, if any Dues the building have electricity? Yes NoQ
lfNlo, are you requesting that the electricity be turned on? Yes 0 No IJ
The building is sprinklered? Yes Q Now
Operations v,ill product dust \vood shavings, or similar material? Yes ❑ No Ld—
Operations Nvill involve the repair or replacement of automobile parts Yes ❑ No,
If yes: Describe the components repaired or replaced.
Does the operation involve the use of welding or open flame? Yes ❑m No 3— y
The business is drinking, dieting or assembly use that will result in an occupant load
ormore than 50 persons. Wes ❑ No a'"
The IoLowing best describes my operations
00fhcc Only Retail Sales LIMedicalfDental ❑Restaurantrrake Out Food ❑Warehouse
❑',N4anufacturing`Distribution (describe process and end product)
❑ Other (describe)
,Zoning . µ.� � Sq Ft Occupied:7V Oce Group:��-�— Occ Load: ��..
## Stories: # Parking Spaces: � TIT Review: YIN Am( Paid$:
Paid BEFORE Final Inspection
Building Permit Entitlement ff:
C oMnlent _
_ 4
Plar ncr Initials: � � ldg€Plan Clieeker h,'tia i# CofO
Initials:
l
HAZARDOUS MATERIALS DISCLOSURE INFORMATION
Huntington Beach Fire Department
California. Health and Safety Code requires the Fire Department to regulate businesses that handle hazardous
materials. Motor oil, hydraulic fluids, gasoline, 'ry cleaning fluid, etc., are considered hazardous materials and
must be disclosed. If you use, handle or store hazardous materials or waste materials equal to or in excess of
the following basic quantities, your are required to disclose:
• 55 gallons of liquid
• 500 pounds of solid
200 cubic feet of compressed gas
Any amount of radioactive materials
• Any amount of Class A explosive
• Any amount of chemicals known to cause cancer z
• Any amount of commercial pesticides
Reportable quantity of any chemical on EPA Extremely Hazardous Materials Substance List
Disclosure is not required for the following:
1. Hazardous substances contained in food, drug, cosmetic or tobacco products.'
2. Upon approval of the Fire Chief, hazardous materials contained solely in consumer products packaged
for use by and distributed to the general public. However, pesticides, herbicides, and ammonium
nitrate fertilizers over tine required disclosure amounts are not exempt from disclosure.
3. The transportation of hazardous materials accompanied by shippingl:apers prepared in accordance with
the provisions of 49 Code of Federal Regulations.
4. Infectious waste generated byhealth care facilities that are regulated under Title 22 of the California
Administrative Code.
Check one of the following:
�No chemicals are used, handled or stored at this business.
Chemicals are used, handled or stored at this business, but do not meet the requirements for disclosure
Chemicals are used, handled or stored at this business. Disclosureforms will be sent to you.
Amounts will be verified by the Fire Department during annual inspections. It is unlawful for any person to
knowingly violate any provision of this ordinance.
I certif?, under the penalty of perjury, that the above information is true and correct to the best of my
knowledge.
Signature Date
Hoi e. Ph+one 'i /
Please cull 714-536-5676 wills questions regarding the Razardoics Alaterials Program.
a
South Coast
Air Quality !Management District
21865 E. Copley Drive
Diamond Bar, CA 91765-4182
(909) 396-3529 htpp://htitvw.agmd.gov
Air Quality Permit Checklist
California Government Code 65850.2 prohibits cities from. issuing a Certificate of Occupancy to a business
without clearance from the local air quality agency. Tlu.s checklist will determine if you need to obtain
clearance from the South Coast Air Quality Management District (AQMD).
Company Name: _�-isi 1 F C-00 hr
Property Address: % 5
City: f 04 Zip Code: 22dY---)
Contact Person: Q nn't n 0 u c, ya L!;:t 'Title (f
Type of Business, fC.,- 4,n�/ %' Telephone:
CJC:�
Applicant: (print name) tAvto y U cl p4 a._t--i Signature:
• Will the far.;lity have any of the following equipment? Yes ❑ No
Charbroiler
Dry cleaning machine
Spray Booth
Printing Press (screen!lithographic/ilexographia)
Internal combustion engine (greater than 50HP) (excluding motor vehicles)
Boiler/combustion equipment (greater than 2 million BTU/hr. maximum input)
Abrasive blasting cabinet/room
Bagliouse%artridge type dust filtez/scrubber
Motor fuel storage and dispensing equipment
• Will any of the following operations be performed? Yes ❑ NO/d--�
Application of paints or adhesives
Etc.hrng, plating, casting, ormelting of metals
Molding and blending of liquids and/or powders
Storage ofacids, solvents, organic liquids or fuels 4
Production of acids, solvents, organic liquids, or fuels
Production of :fumes, dust, smoke or strong odors
1
• If you answered "No" to both questions,this checklist is your clearance from AQMD, i
i
• 1f you answered "Yes" to either question, you must contact AQlv1D 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 (800) 388-2121.. t
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ry