HomeMy WebLinkAbout15081 GOLDEN WEST - CofO3
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APPLICATION FOR CERTIFICATE OF OCCUPANCY '
� . CITY OF HUNTINGTON BEACH
tiuNTPcaoH8E#nj DEPARTMENT OF COMMUNITY DEVELOPMENT
(PRINT OR TYPE ONLY) I�� O DTI E
Address — G uTwY,fAl ,4 District
Business Name �� ��( Tel.
Business Typed-'liGE Occ. Group_
BUILDING OWNER BUSINESS OWNERIMANAGER
Name_—
A -'dress t- 1 f-rc;1Home f ,to Address
City-.... �� ( i,'n --- Te��/' City�Cywzk
ii —HomeTel.g
THIS USE WOULD BE DESCRIBED AS:
❑ NEWLY CONSTRUCTED BLDG. ❑ CHANGE OF OWNER r}
CHANGE OF OCCUPANT I
I[ EXISTING BJiLDING lT� CHANGE OF USE ❑ ADDITIONAL OCCUPANT #
Indicate former use, if any Occupancy Gr. Ai Div. I
SQUARE FT, OF BUILDING TO BE OCCUPIED
SUPPLEMENTAL' INFORMATION
(FOR OFFICE USE ONLY)
ZONING
i
OCCUPANCY GROUP
`�.,
�120`�
PLAN CHECK
N
NO. PARKING S,o C „ES
OCCUPANT LOAD
PERMIT NO.
—.
HEALTH DEPT, APPROVAL
NO. OF STORIES —
ADMIN. ACTION
--
UTILITIES RELEASED _
Q "1
APPROVED BY
16cdi 2D-� CERTIFICATE OF OCCUPANCY FEE
DA11i CHANGE OF
$
—
USE OR OCCUPANCY FEE
$
TOTAL
75-0399sv. 11190
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COMMUNITY DEVELOPMENT
SUPPLEMENTAL INFORMATION!
1.
BUSINESS ADDRESS _. l (DC..O,N Ufa
A J6 ,
2.
Person to contact in case of emergency.
Telephone number: g �i7o
3.
Does the building in question have electricity?
Yes
No
(a): If No, are you requesting that the electricity be
❑ Yes
turned on?
❑, No
4.
The building is sprinklered?
❑ Yes
9No
5.
Operations will produce dust/wood shavings or similar
material?
❑ Yes o
No
6.
Operations, will involve the repair or replacement of
❑ Yes
automobile parts?
*No
If Yes:
(a) Describe the components repaired or replaced.
_ 1 '
(b) Does the operation inve!ve the use of an open flame? ❑ Yes
No
7.
The business is drinking, dining or assembly use that
will
result in an occupant load of more than V persons. '
❑ Yes
No
8.
The best describes my operation;
i
Lofflowin
icE= Onl
Retail Sales
Warehouse
Manufacturing/ Distribution (describe process and end
product)
-
j
3
Restaurant / Take Out Food
Medicai / Dental
Other (doscr ibe) --_
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SUPPUMEIvM INFORMATION
SilPKIEMENTAL INFORMATION (Continued)
Does the operation involve any of the following materials? El Yes
�No
If
Yes, indicate quantities: -
Wterial
1.
Quantity
Flammable liquids
Class I-.
� —
Class 1-8
Class I-C
2•
I
Combustible liquids
Class II
Class III-,4
3.
0mb1naI�nlammable liquids
4.
Flammable gases
5.
Liquefied flammable gases -•----_
Flammable fibers - loose ---.----
r,
Flammable fibers - baled
Fla rrtmable solids
9-
Unstable materials l
10.
Corrosive Liquids f
I. 11.
Oxidizing- 9
material gases
12.
Oxidizing !
g material liquids
13
Oxidlzng material - solids
14.
Organic. peroxides
j
Nitromethane (unstable materials) l
16.
. Ammonium nitrate
I,
17.
Ammonium nitrate corrtpound mixtures
c containing more than ' 60% nitrate
by weight
i 16•
Highly toxic material and ?
E
poisonous gas
' 19y.
Smokeless powder
20•
Black sporting powder ..
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I.,_ hereby certify that the above information is ' true and :correct to � the hest of my knowledge.
01
Signature
Date ;
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SOUTH COAST AM QUi-W T V MANAGEMENT DISTRICT
(illonresidential Buildings Only)
Location of Subject Property:..
Property Owner lame:_
lame of th",: person preparing this Porn, in print and signature.
Name: ��fGL�� �5"�/ ^�j� a
,
- - _ - ...�O_ •__ - _Signature.Vfor
The person preparing this form must be the same person applyiuilding permits. Please,enswer the
following questions regardinq your proposed occupancy of the subject building. IF YOU LSO NOT`KNOW
THE ANSWER TO A QttESfl(,'N, MARK IN THE "YES" COLUMN:
AC440 PERMITTING CHECKLIST
ytS NO
I . Does your facility use e.ny internaf combustion engines greater than 50HP?
2. goes your facility involve mixing, Wending, or processing any ,31v&1ts, I
adhesives, paints or coatings?
3. Does your facility create anti dusts or smoke?
4. Does your facility refine any Iiqui,"s or solids or reclaim any metals?
5. Does your facility plate or coat; anything? ;
6. Does your facility have any combustion equipmeni (i.a. boiler, furnaces, �+
broiler, balking ovens, etc.) rating greater tPan 2,(3{39.00q 3TUIHR
7. Does your facility handle or store solvents or rotor fuei?
S. Do you use or store any acids?
9. Dry you use any chemical process? __ ----�
10. Do you use any solvents for clean-up? _
11. Are you a dry cleaner, restaurant'w th a charbroiler, body shop, gasoline
station, printer, or part coater?
i 12. fs the subject building located within one thousand (1,000) feet of any
school,? PROPERTY LIME TO PROPERTY LINE. GRADES K-12.
If you have marked "NO" in -111 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;
21865 E.,Copley Drive
Diamond Bar, CA 91765-4182 i
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Please call: Plan Check (909)`396.2000
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