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_ , APPLICATION FOR CERTIFICATE OF OCCUPANCY
CITY OF HUNTINGTON BEACH i
�. �? OV DEPARTMENT OF BUILDING & SAFETY Jr
HUNTINGTON KAGN / t�, (PRINT OR TYPE ONLY) ! DATE. i
ail
.Address � ( District
BLsiness Name s/� Tel.
fZoo.
Business Type =�r✓�✓�'`�/ Occ. Group
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BUILDING OW ER '/ , NEMMANAGER
Name t I/ d,�?,G=� Name Home Z
Address "`�✓� Address
Ss"1iE. c
City--�=K'�L.G- TeL�fCity � Home TeL
THIS USE'WOULD BE DESCRIBED AS: f
r
+ LDG. ❑ CHANGE OF OWNER " CHANGE OF OCCUPANT
C❑ NEWLY CONSTRUCTED B
EXISTING BUILDING {I ❑nCHANGE OF USE ❑ ADDITIONAL OCCUPANT
Indicate former use, if any f Jfj If D% Occupancy Gr. _Div.
S
SQUARE FT. OF BUILDING TO BE OCCUPIED ro 'Q j Ci' Gf l',-, VC
NOTICE:
1,' Occupancy of any. building is prohibited and a business license will not be issued until the buildingias been
inspected and a certificate of occupancy is issued.
2. No electrical' service will be'released for any existing building until the service has been inspected and
certified safe. All applicants for occupancy in an existing, building are required to schedule an electrcal'
'fuse up' inspection in the Department of Community Development at the time this application is filed,
3 Change of occupancy or use inspection fee. Whenever it is necessary to make inspection of a building or
premises in order to determine if a change maybe made in the character of occupancy or use of the building
or premises which would place the building in a different division of the s me group of occupancy or in a
different group of occupancy, a change of occupancy inspb_Jon fee of $ ` shall
be paid to the city.
4. Huntington Beach Fire Codse Section 10,208 requires thatbuilding numbers must be a minimum of four (4) ;
inches in height with one half (1/z) inch stroke, and of a contrasting color from the background. These
numbers must be posted on your buildirgin a location that is visible from the street. '
5. Huntington Beach Fire Cade Section 10.301 requires fire extinguisher selection and distribution per the
National Fire Protection Association pamphlet 10 (see reverse side).
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TRAFFIC I�d.f����r � E
BATE PAID—,.,r.
A IOUNTMCC- t e � ate..
NAM " (FOF? OFF USE.ONLY) L
ZONING
OCCUPANCY GROUP PLAN CHECK NO NO PARKING SPACEST
OCCUPANT LOAD a� PERMIT NO. _ HEALTH DEPT. APPROVAL —
NO, OF STORIES ADMIN. ACTION UTILITIES RELEASED
` . /o « CERTIFICATE OF OCCUPANCY FEE $
APPROVED BY DATE CHANGE OF USE OR OCCUPANCY FEE
TOTAL g
FORM 75-039 REV 2102 Re -ORDER; _BAND DOLLAR714 342-1148 81JIILDIIN�.Q SAFF. rY
SUPPLEMENTAL INFORMATION
1.
BUSINESS /%J`Z %�ilS/JC Zf)
ADDRESS �-
t
2,
percor to contact in case of emergency.f� 11� 7f
Telephone cumber:
3.
_Does the building in question have electricity?
E5Vfes
C No
(a) if No, are you requesting that the electricity be
❑ Yes
turned one
❑ No
4.
The building is sprinklered?
211Yes
C No
5.
Operations will -produce 'dust / wood shavings or similar
material?
❑ Yes
Kr'N o
6.
Operations will involve the repair or replacement of
❑ Yes
automobile parts?
No;
If Yes:
(a) Describe the components repaired or replaced:
(b) Does the operation involve the use of an open 'flame?
7
F
❑ Yes
�No
7.
The business is; drinking, dining or assemblyuse that will
'
result in an occupant load of more than 50 persons.
❑ Yes
-KNo
8.
The following best describes my operation;
Office Only
Retail Sales
Warehouse;
Man ufacturirig/ Distribution ;(describe process and end product)
E
C
Restaurant /'"fake Out Fool
Medical / Dental
#
Other ;(describe)
E
t
Q;Ms,;al M4PNTAI IIMMA`rtdiP:t'
-SUPPLEMENTA ,. INFORMATION (Continued) t
Does the .operatioll involve any of the following
materials? 0 'Yes
ei o
1f°es;
indicate quanfifles.
Mater,al Quantity
_
1.
Flammable_ liquids
Mass ,I-d
Class 1-B
+Blass I-�.
I
2.
Combustible liquids
Class 11
Class 111-
� .
Combination flammable liquids
quids
_ _
Flammable gases
5.
Liquefied flammable gases
6.
Flammable fibers - loose
7.
Flammable fibers - baled
8.
Flammable solids
9.
Unstable materials
10.
Corrosive liquids "
11.
Oxidizing material - gases
12.
Oxidizing material - liquids
13.
Oxidizing material - solids
14.
Organic peroxides
M
Nitromethane (unstable` materials
16.
ammonium nitrate 4
17.
Ammonium nitrate compound mixtures
containing more than 60% nitrate
by weight
16.
Highly toxic material and
poisonous _ as
19,
Smokel° as owder
$ 20.
sporting powder
:Bla�—k
rebycertify hat the above information
is true ;.nd correct to
test of y knowledge.�,
Signature
Date
s
c
i
South Coast 3'
AIR QUALITY MANAGEMENT DISTRICT
21865 E. Copley Drive, Diamond Bar, CA 91765-4182 (909) 396-2000
AM QUALITY PERART CHECKLIST
i
for nonresidential buildings only
Company Name:
Location of Property: /57`i_G
City:
'Z' dip Code:
Contact Person Ll1 C� C 'x itle: _
/�--
Telephone Dumber: /Wo7O0 Pax Number: �� 7-
Type of Industry;m usiness:
To apply for a nonresidential building permit, you must complete this checklist. If have any
questions about completing this checklist, please call(800) 388-2121.
YES NO
1. Will the facility have a charbroiler?
2. Will any internal combustion engine with greater than 50 horsepower
operate at the facility (excluding motor vehicles)?
3. Willl operations at the facility involve mixing, blending, or processing of
solvents, adhesive is or coatings? [ ] [
4. Will dust or s ke)W
generated at the facility? [ ] [ 1
5. Will ref . of a� liquids or solids be done at the facility?
6. Will any lating.or coating of materials be dome at the facility?
7. Will airy ombpstion equipment rated greater than 2,000,000 BTU/hr be
operated a e facility?
8. Will any a s, solvents, or motor fuel be used or stored at the facility?
6. Will any c liquids or s be reacted or produced?
10. Wiii any ens e used to y r c e products at the facility?
11. Will an PC r re c ' u s operate at the facility?
Applicant: Signature:
(Print nan / nearly)
If you have 'rr ked "NO" in the boxes, an air quality permit is r,, t needed at this time,
and this f-hec ' t is your w Tien release.
If you marked "PEES" in any of the boxes, you must contact the South Coast Air Quality
Management District (.A:QI%M). Please read the requirements on the back of the checklist.
(800) 388-2121
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