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J� >� APPLICATION FOR CERTIFICATE OF OCCUPANCY ,
CITY Or HU�ITINGTON BEACH hg q
DEPARTMENT OF COMMUNITY DEVELOPMENT �/ /J i /
F HUNTINGTON SACK (PRINT OR TYPE ONLY! DATE
Address / 3 `f I e "j-/!I S/ S top, District
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Business Name %Cfi L O IyV'5' Tel Yell? g a
I Business Type — Occ Group
BUILDING OWNER T BUSINESS OWNERIMANAGER
I Name
V t' I �v S Name_
H me
oC% Y �f f1 Cy ��/P✓Z--44�f Address %
Address 77
M City �Te 3�C�ity �• ����T (L— Home Tel
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THIS USE WOULD BE DESCRIBED AS:
❑ NEWLY CONSTRUCTED BLDG. ❑ L :ANGE OF OWNER CHANGE OF OCCUPANT
EXISTING BUILDING ❑ CHANGE OF USE ❑ ADDITIONAL OCCUPANT
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Indicate former use, if any ,, �j Occupancy Gr Div +
SQUARE FT. OF BUILDING TC BE OCCUPIED-L O .?7 1
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(FC`" OFFICE USE ONLY)
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ZONING— [
SUPPLEMENTAL INFORMATION
OCCUPANCY GROUP
�-2— PLAN CHECK NO.
NO PARKING SPACES
OCCUPANT LOAD
PERMIT NO.
HEALTH DEPT APPROVAL —
NO. OF STORIES
ADMIN. ACTION
UTILITIES RELEASED 9
U � RTIFICATE OF OCCUPANCY FEE
$
APPROV D BY
DATE ANGE. OF USE OR OCCUPANCY FEE
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TOTAL
$
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75.039 Rev. 11/90
COMMUNITY DEVELOPMENT
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SUPPLEMENTAL INFORMATION
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BUSINESS ADDRESS /5_ 'A �i e�ti�-maces �G
` 2.
Person to contact in case of emergency -
Telephone number: 71
3.
Does the building in question have electricity?
Yes
No
(a) If No, are you requesting that the electricity be
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turned on?
No
XYes
4.
The building is sprinklered?
❑ No
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5.
Operations will produce dust/wood shavings or similarYes
'
material?No
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S.
Operations will involve the repair or replacement of
❑ Yes
NO
automobile parts?
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If Yes:
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(a) Describe the components repaired or replaced.
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(o) Does the operation involve the use of an open
flame? ❑ Yes
4No
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The business is drinking, dining or assembly_ use that
will
result in an occupant load of more than 50 persons.
❑Yes,
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8.
The following best describes my operation;
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ail Sales
W taus
Manufacturing / Distribution ( scribe process and end product)
Restaurant/Take Out Food
Medical /Dental
Other (describe)
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SUPPLIMENTAL INFORMATION
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SUPPLEMENTAL INFORMATION (Continued)
Does the operation involve any of the following niaterials-7 Yes
No
If Yes, indicate _ quantities:
Material Quantity f
1. Flammable liquids
I Class I -A
I Class i-B
Glass i-C
2. Combustible liquids
Class Il k
i Class Ill -A I
3. Combination flammable liquids
4. Flammable gases
5. Liquefied flammable gases
F 6. Flammable fibers loose
7. Flammable fibers - baled
8. Flammable solids
9. Unstable materials
10. Corrosive liquids ,
f 11 Oxidizing material gases {
12, Oxidizing material —liquids
13. Oxidizing material - solids
` 14. Organic peroxides _
15. Nitromethane (unstable materials)
16. Ammonium nitrate {
17. Ammonium nitrate compound - mixtures —~
containing more than 60% nitrate
by weight
18. Highly toxic material and
poisonous , gas
19. Smokeless powder
20. Black sportingpowder
hereby certify that the abovi information is true and correct to
the best of my I owledge.
Signature Date
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:nie form in print and sigraa,ur(,�; �i
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frT 2 Sig.natura._�
pLr r y�r��i� q this form must be the same person appiying for building permits "'-ase answer the
rails v °r? q,"ie' .,on i your proposed occupancy of tl.e su,,,jPct bu►kiing, IF YOL J NOT KNOW{ a HE ANSV,!L-9 -I rO A O tES-1 ION, MARK IN THE "SEES COUMAN:
1 MID PrgMpT NMG 1
YES Mo
1- Dries your fscilitj us cs any internal combustion engines greater than 50HP?
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2. Dees your a,; lity involve mixing, blending, or processing any solvents,
adhesives t+a.ints or coatings? _ —__
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3. Does your facility create any dusts or smoke?
' 4. Hoes your sr: cility refire any liquids or solids or reclaim any metals'?
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5. Does youi fr ?lity plate or coat anv hing? ��-
6. Does your facility have any combustion equipment (i,e. boiler, furnaces; /
broiler. baitis,ig evens, etc.) rating greater than 2,000,00C) B i tl HR?
7. Doe-9 your facility Dandle or store solvents or motor fuel?
U 1. YOU L :« Or steam am acids? ,
I 0. Do you � so any ch°~-mical process?
P 10. Do you use any solvents for clean-up?
Are yczi clewier, restaurant with a charbroiler, body shop, gasoline
M ation. pri,,iLnz ur part coater?
2': is riao subject building located within one thousand (1,000) feet, of any
k s� h zs i 3 PRO' ` ''.1�"i Y LINE 'S O PROPERTY LINE. GRADES K-12.
If you have rrar},,6 ! "MC' in i c lurmrgs, you do not need an Air duality permit at this time. if you havz marked
ii ay S1.ai'Ei'o ri. .1 G ' Es col vmr4 voU r1lust ao tact the Smith S'a it Qual;t�r Management District located at: iA
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21865 E. Coplev Dri-v
Diamond Ear, CA 91 755- 71832
Pie sc call: Plan Check (909) 303-2000
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Government Code Section 615850.2(b) requires that the City of Huntington Beach not issue the final
.. he requirements
ements of the So
uth
or is t
t has met
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the applicant s., e
certificate of occupancy unless pp
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) velo meat must
Coast Air Quality Management. District (AQMD). The Depa� tment of Community � p .,
obtain a writ!:en release from AQMD to show the applicant has complied with this law. The check I
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 can accept the
check list as the release.
3. If there are any "yes" answers in the list, the applicant must contact an g I
AQMD engineer by calling (714)-396-2000 to find out whether air permits are
required for the proposed construction project. l
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4. If air permits are not required, the applicant will obtain a written release from �
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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 AQMD to go through the above procedures, the applicant is
advised to contact AQMD immediately after applying for building permits.
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ADDITIONAL SUPPLIMENTAL INFORMATION
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