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Business Addre
Business Ownea
Business Name
Business Type _
Certificate of Occupancy No. 0200 / 0 •- leo t-
APPLICATION FOR CERTIFICATE OF OCCUPANCY
CITY OF HUNTINGTON BEACH — DEPT. OF BUILDING & SAFETY
(3'd Floor - Must Apply In -Person)
Date reb 7'-1 Lp %o
`11 Zip Code
Telephone No.71y- 5Bq "41i' AI
Bus. Phone I y - Ste^
Property Owner Information (required) Tenant/Emergency Contact (required)
NameC3o1 L2ys. 'V%e �1�r1(- '1.tC Name �y ;e She..,, s
Address 51c1 Z Dobipiy c . W to l Home Address 171Gl
CityJAVAL,%46 eh5a State/Zip V-6-15 Cityl uo% ;,,a_ n(3emhState/Zip Ci►. , cI7-��_
Telephone No. 21L1 S99 - Z;rq 1 Telephone No.:7%4 - 5; 3 Z. -ao 1-1
THIS USE WOULD BE DESCRIBED AS:
❑ Newly Constructed Building or )F Existing Building
CHECK ALL THAT APPLY:
❑ Change of Property Owner t4 Change of Occupant 0 Change of Use ❑ Additional Occupant
■ Indicate former type of business N%a
■ Are you requesting that the electricity be turned on? YesWNo❑
■ Is the building sprinklered? Yes l?No❑
■ Will operations produce dust/wood shavings or similar material? YesQNow
■ Will operations involve the repair or replacement of automobile parts Yes ❑No )4 If yes: Describe the
components repaired or replaced.
■ Does the operation involve the use of welding or open flame? Yes QNo Ig
■ Will the business be a drinking, dining or assembly use with an occupant load of more than 50 persons?
Yes QNo l�
■ The following best describes my operation: ❑ Office Only 0 Retail Sales 0 Medical/Dental
0 Restaurant/Take Out Food )< Warehouse /Manufacturing/Distribution
(describe process and end product)
V Other (describe) My :e_ . h►vo�:o �t_rge
For Official Use Onl
Occ Group: Area: Ins 0 5 Occ Load:
Occ Group: Area: — on Occ Load : 2
Occ Group: Area: Occ Load: _
Total Sq Ft Occupied: &0,51P No. of Stories:TIF Review: Y/AQ
Bldg. Permit # Entitlement #: Zoning: 11
Plnr Initials: Date: Plan Chkr Initials Date: W/'Q Insp Initials: 2J Date: �I]
f
Condi io of Approv/al or Other No es:
Inspection Date:
(G:Building/Formsldocument id goes here)
4
'South Coast
Air Quality Management District
21865 E. Copley Drive
Diamond Bar, CA 91765-4182
(909) 396-3529 htpp://www.agmd.gov
Air Quality Permit Checklist
California Government Code 65850.2 prohibits cities from issuing a Certificate of Occupancy to a business without
clearance from the local air quality agency. This checklist will determine if you need to obtain clearance from the
South Coast Air Quality Management District (AQMD).
Company Name: bAg,;y,s VoA0
Property Address: i 6-13 \ Ty, Von
City: \AO h V: h C,h 996 Zip Code: 2-(o'-19
Contact Person: mg) , e,5 V:n v\ cS Title:
Type of Business: N Telephone: O — 51
Applicant: (print name) TA 0*4 Gy owe5 Signature: A14
[]Will the facility have any of the following equipment? Yes o 11
Charbroiler
Dry cleaning machine
Spray Booth
Printing Press (screen/lithographic/flexographic)
Internal combustion engine (greater than 50HP) (excluding motor vehicles)
Boiler/combustion equipment (greater than 2 million BTU/hr. maximum input)
Abrasive blasting cabinet/room
Baghouse/cartridge type dust filter/scrubber
Motor fuel storage and dispensing equipment
Will any of the following operations be performed? Yes 11No
Application of paints or adhesives
Etching, plating, casting, or melting of metals
Molding and blending of liquids and/or powders
Storage of acids, solvents, organic liquids or fuels
Production of acids, solvents, organic liquids, or fuels
Production of fumes, dust, smoke or strong odors
❑ If you answered "No" to both questions, this checklist is your clearance from AQMD.
C] If you answered "Yes" to either question, you must contact AQMD to determine if air quality permits are required.
If permits are needed, AQMD will assist you in submitting permit application(s) and then provide you with a
clearance letter. You can call AQMD at their Small Business Assistance Office at (800) 388-2121.