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APPLICATION FOR CERTIFICATE OF OCCUPANCY
CITY OF HUNTINGTON BEACH pp �qj
DEPARTMENT OF COMMUNITY DEVELOPMENT %sue -2 ^ /3
rturMNK70 r woos DATE
' tPRINT OR TYPE ONLY)
r Address A) b MCI r District
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Business Name ✓ Lc' __ 7) Z Z_G% Tel
Business Type �"I �� /� �" Occ Group
BUILDING OWNER BUSINESS OWNERWANAGER
r Name k E h r, ry Name ate_4L F nr Ir
`HomellII � l F
Address //4 I n _ Address 7/ �� l�fg �.HO %
I City—Au"i '- /Ze a C Tel City Horne TeL 6 %�
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THIS USE WOULD BE DESCRIBED AS:
❑ NEWLY CONSTRUCTED BLDG I CHANGE OF OWNER CHANGE OF OCCUPANT
CJ EXISTING BUILDING ❑ CHANGE OF USE ❑ ADDITIONAL OCCUPANT
Indicate former use, if any Y �'iLc g ce y' Occupancy Gr Div j
SOUARE FT. OF BUILDING TO BE OCCUPIED
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(FOR OFFICE USE ONLY)
SUPPLEMENTAL INFORMATION of
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ZONING
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OCCUPANCY GROUP
PLAN CHECK NO,
NO PARKING SPACES
OCCUPANT LOAD
PERMIT NO
HEALTH DEPT APPROVAL
NO: OF STORIES
ADMIN, ACTION
UTILITIES RELEASED
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CERTIFICATE OF OCCUPANCY FEE
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�Zrrmo BY DATE
CHANGE OF USE OR OCCUPANCY FEE
TOTAL
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75-039 Rev. 11/90
COMMUNITY DEVELOPMENT
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P
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SUPPLEMENTAL INFORMATION
1.
BUSINESS ADDRESS Z nl.? Ti N
2.
Person to contact in case of emergency -
Telephone number:
3.
Does the building in question have electricity?
12-Yes
❑ No
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(a) If No, are you requesting that the electricity be
C4 Yes
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turned on?
❑ No
'
4.
The building is sprinklered?
❑ Yes
-B"No
5.
Operations will produce dust/wood shavings or similar
material?
❑ Yes l
,ENO
6.
Operations will involve the repair or replacement of
El Yes 4'
automobile parts?No
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If Yes:
(a) Describe the comp*)nrots repaired or replaced.
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(b) Does the operation involve the use of an open flame? ❑ Yes
43-•No
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7.
The business is drinking, dining or assembly use that will
result in an occupant road of more than 50 persons.
❑ Yes
�^ No {`
8.
The following best describes my operation;
Office Only
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Retail Sales
Warehouse
Manufacturing / Distribution (describe process and end
product) j
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Restaurant / Take Out Food
Medical /Dental
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Other (describe)
SUPPLIMENTAL INFORMATION
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SUPPLEMENTAL INFORMATION (Continued)
Does the operation involve any of the following materials? ❑ ve;;
No
If Yes, indicate quantities:
Material Quantity e
1.
Flammable liquids
Class I -A
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Class I-B
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Class I-C
2.
Combustible Liquids
Class II
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Class III -A
3.
Combination flammable liquids
4.
Flammable gases
5.
Liquefied flammable gases
6.
Flammable fibers 2loose
7.
Flammable fibers - baled
8.
Flammable so'ids
9.
Unstable materials--
10.
Corrosive Liquids
11.
Oxidizing material - gases
12
Oxidizing material - liquids
13.
Oxidizing matorial - solids
f 14.
Organic peroxides
15.
Nitromethane (unstable materials')
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16.
Ammonium nitrate
17,
Ammonium nitrate compound „oixtures
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containing more than 60% nitrate
by weight
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' 18.
Highly toxic material and
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poisonous gas
19.
Smokeless powder
20.
Black sporting powder
hereby certify that the above information
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is true and correct to
the best of my knowledcu
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s. _
ature
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44 P Q faji (. r, rn y ((!! t n
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of Sui is ` ppf. pc—v`;,
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Name of the person p.epa,`:�q ;h s form. in pritlt
Nance'
' The person preparing tt is tur rn must be the same person applying for building p rraits. Please answer the
ollowing questiai.s regarding your proposed occupancy of t� sZ-jact building YOU DO NOT KNOW
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THE ANSWER TO A QUESTION, MARK IN THE "YES„ CLlL0P)!N,
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AQMD PERFA oTIN.0 CHECKLI zf
YES NO
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1. Goes your facility use any internal combustion engines greater than 50HP? _ ___
4.
2. Does your facility involve nixing, blending, or processing any solvents,
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odhesives, paints o; coatings
3. Does your facility create any dusts or smoke?
4. Does your facility refine any liquids or solids or reclaim arty metals?
5. Does your facility plate or coat anything?
6. Dods your facility have any combustion equipment (i.e. boiler, furnaces,
b �
broiler, baking ovens, etc.) raring greater than 2,000,000 I T t_i1HR?
i 7. Does your facility{ handle or store solvents or mctor fuel?
8. Do you use or store an;, acids?
9. Do y^u use any chemical process?
10. Do you use any solvents for clean-up?
11. Are you a rir�f cleaner, restaurant with a charbro lar,,bcdy shop, gasoline
stator., printer, or part coai:er?
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12. is the subiect building located within one thousand ('i, ,a0) feet of any
PROPERTY I_tNE- T0 PROPERTY LINE. GRADES K-12.
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school?
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it you have ma, lied '140" in all columns, you, do not need an Misr Quality too 6, "-vc ai i`narlCGd
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any questions in the ,Y4 S ' Column you a must contact the S ,;, to Coast Atr v ,_..:_ ry !ocated at.
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21865 E. C:clp!R.,y L ; ive
r�°amond tsar, CA C -418
Please call. Plan Check tc.Cl91 3SC•2000
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Government Code Section 55850.2(b) requires that the City of Huntington Beach not issue the final
certificate of occupancy unless the applicant has met or is meeting the requirements of the South
i Ccast Air Quality Management District (AQMD). The Department of Community Development must
i obtain a written release from AQMD to show the applicant has complied with this lava. The check
list on the reverse side is designed to help the applicant and the building division to meet these
requirements.
1. The applicant (the same person who applies for permits from the
Department of Community Development) must complete the check list
which can be obtained either from the Department of Community
Development or at AQMD.
2. If all boxes in the list are checked "no", the Building Division car, accept the
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check list as the release.
3. If there are any "yes" answers in the list:, the applicant must contact an
AQMD engineer by calling (714) 396-2000 to find out whether air permits are
M required for the proposed construction project.
I s
F 4. If air permits are not required, the applicant will obtain a written release from
AQMD.
5. If air permits are required, the applicant must submit the necessary permit
applications before the release can be issued.
Because of the time it may take for AUMD to go through the above procedures, the applicant is
advised to contact AQMD immediately after applying for building permits.
E
A
(1360D).
( ADDITIONAL SUPPLItMENTAL INFORMATION
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