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APPLICATION FOR CERTIFICATE OF OCCUPANCY
CITY OE HUNTINGTON BEACH
_ DEPARTMENT OF DEVELOPMENT SERVICES y
HUNTINGTON KA011 ! ,I.'r ,ir,lr, DATE
1
^ ddress _ ,e'r! �_ ...._..'? •H4 ram✓ 5 '�T 1c'�� !ti! _,.;_CSr- s4 ..._ .�._� ?irstr;Ct. _ �_
74usiness Narna— TeE_ _ I
mousiness T pe Orc Group______
BUIL£` Y4(-, UWNFr"r FUSII`t �:, �0"WNER/MANAGER
Name
Amr.
drr'csc;U-'5_e!
1,ome Tel S�rS-555''
THIS USE WOULD BE DESCRIBED AS:
D NEWLY CONSTPUCTED R!.OG El l;IIANGE OF 1JVP4t.-h L.`' CHANGE OF OCCUPANT
[ EXISTING BUILl !NG L J .M,,Nz-,E `J- USE } � .A[,r I IuNAI 0CCUPANT
Indicate fovrn- r ,1se, if any
SOUARE FT. OF Btht DING TO BE
` NOTICE: 1: Orccuparcy of arid buiid,ng t:4; pro li!-,Oed arid-3 t; , .!r!. : ticen-_e will not L?.: issu-d untii the bUidiny has
been inspec!edi and a rer*,Jir_ate of rtccu 7ariry ii;
i
2 No Jectrical sprvice Vui,, E:e R E c..e1r lot any bi!0cli lg until Iflo been trispected and
cotifw?d S-,afF': i'Ji atpp u';,Ant5 to-, S^ an E ,._img build1 aQ ciflp r'�,quirp l to i,,,1her!vfP an elEc!ncai
tip i•'pF:t;tYclni(kthe i"'4YpflrtrTl;nt l,7i +`„ieVEl<�pr'flr."!t .k',.'4if.Et,S 8I {1h+5 tirtrP tn!sappktCtatic;n is Ned.
I Change vt occupancy Or use inspection tee. +41her !v er It is nAG :,Sar,r tr, rnal:e in peGtirn of a building
or prem,ses in Or+dE r to d eiormiir.r, J a i hallae nl?y hp Tnddi.: iii the cna+ �'n er of occupancq or use Of ibe �
butd!rtG or premjE s vt+}:acf~ i 7 lu f , <::�E: the L..+t.av7q it, a dtftt lE r 1. riiv SiOti of ri'+ • S"I'me group of Occupancy
or in a difffrent group of Occupancy, change rt accatt7ar,.,y inspwt t'rrin fc, ,;t �� _ ___
snail de paid to the city.
r 4. Huntington Beach Fire Code Section tt, 203 requires, that bti4ding nurnt,ers must bit a minimum of four
! - (4i ,nc,'+es in lieight ` 0 i":'alti I "t i:ir;h S{roke, ar-1 of el c.,on1r%a++>{ ng cr lcir from the LaCKground.'I hose .
numbers mtJSt Lie pGStr. d ,nr} your building in a incaoon that i:' vis bie fit^rn the Si,eei.
5. Huntingtoi, Beach Fire Cade Section 10.3-')1 rr dire z fire exiingin-Ihe, selection and distribu!ion pe. I
the National Fi.i} Protection As,ryociation pamphiel if) ispe river se s!de�_
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(FOR OFFICE USE ONLY)L� .. -- -•
SUPPLEMENTAL INFORMATION 2 -
caralNG
OCCUPANCY GROUP._. s PLA11 CJ,t.;ri NO No PARit1NC:`SPACES _
OCCUPANT LOA[, PFRr✓tIC "40 _ _ __._-.___. __ - .. HEALTH DEPT. AP?ROVAL —
NO OF STORIFB - AOMI r^^+ 'l'r IN ._ 0TlLITIES REp EAS1-D
_m 1 _ CERTEFICATE "Dr OCCUPANCYi I tr
A CdED $Y *Dj
E CHANGE C OF UiE OR rJCi iIP<1fiv" FEE ^ M
TJTAL
r5{Y:19 ar ✓ f r nr t 7 r tR G I F 13
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SUPPLEMENTAL INFORMATION
BUSINESS ADDRESS £ Ft 'r _ { F ;°C'
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`
2.
Person to contact in case of emergency 1,. r k %•
Telephone number:
3.
Dues the building in question have electricity? t2;Yes
'
ONO
If No, are you requesting that the electricity be Oyes
`
_a.
turned on: ONO
h
I
4.
The building is sprinklered? ❑Yes
RNo
5.
operations will produce dust/wood shavinaa or similar
material? ❑Yes
i
RNo ,
F
6.
Operations will involve the repair, or replacement of Oyes
automobile parts? ONO
i
If yes:
(a) Describe the _components repaired or replaced.
(b) Does the operation involve the use of an ope°. flame?' E[Yes
ONO - I
7.
The business is drinking, dining or assembly use that will
result in an occupant load of more than 50 persons. Oyes
•
�o '
8.
-Ae following best describes my operation:
Office Only
Retail Sales
warenouse
Manufacturing/Distribution (describe process and end
product)
Restarzrank Take Out Food
Medical/Dentt.l
Other (describe)
1
(12/8/86)
(0562D)
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i
s
II
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SUPPLEMENTAL INFORMATION (Continued)
Does the operation involve any of the
following materials? OYes
ra
9No
If Yes, indicate quantities:
Material
Quantity
1. Flammable ligji.ds
Class I-1
Class I-B -
Class I-C
2. Combustible liquids
Class IL
Class III -A
4-
_3. Combination flammable liquids
4. Flammable gases
5. Liquefied flammable -jases
6. Flammable fixers —loose
-
i 7. Flammable fibers - baled
8. Flammable solids -
Unstable materials
` 10. Corrosive liquid
11.-Oxidizing material-- gases
12, oxidizing material - iiqui,is
13. Oxidizing material - solids
14. Organic peroxides
15. Nitromethane (unstable materials)
16. Ammonium nitrate
17. Ammonium nitrate arampound mixtures
' containing_ more than 60% nitrate
by weight
18. Highly toxic material and
.poisonous gas
19._ Smokeless powder
20. Black sporting powder
I hereby certify that the above information is true and correct to the
best of my knowledge.
Signaturtz
Date
(0562D)