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• CERTIFICATE OF OCCUPANCY 020 -
�� CITY OF HUNTINGTON BEACH —
DEPT. OF PLANNING & BUILDING APPLICATION
HUNTINGTON BEACH (3`d Floor — The Applicant Must Apply In -Person)
Business License # o
Business Address :F-rMk7 Ln
Business Owners Name
Business Name P05 V, 5 h o p
Business Type
C
Date / /— 5 v�0/q
Zip Code c
Telephone o. /a.Z- a so-aooc,
Bus. Phone 5,9r12
Property Owner Information (required) Tenant/Emergency Contact (required)
Name j ph h T)eLayrr, Name
Address 5/- ,[30z5;a 14Y2 4:t- l0 / Home A dress lol"I/Z
City State/ZipCA ga6yCity: L,Gj ift(�� State/Zip tA
Telephone No. 7/y 3�S' 2- ff 3 --I— Telephone No. DODD
THIS USE WOULD BE DESCRIBED AS:
❑ Newly Constructed Building or X Existing Building
IS THIS BUILDING SPRINKLERED? Yes ❑ No1
CHECK ALL THAT APPLY:
❑ Change of Business Owner ❑Change of Occupant El Change of Use ❑Additional Occupant
■ Indicate former type of business
■ Are you requesting that the electricity be turned on? Yes Nof
■ Will operations produce dust/wood shavings or similar material? Yes❑
■ Will operations involve the repair or replacement of automobile parts
components repaired or replaced.
■ Does the operation involve the use of welding or open flame? Yes❑
Nov,
Yes❑ Nq,N If yes: Describe the
•z
■ Will the business be a drinking, dining or assembly use with an occupant load of more than 50 persons?
Yes❑ No�
■ Will there be storage racks, gondolas, or shelving exceeding 5feet 9 inches in height? Yes[] N
■ The following best describes my operation: � Office Only [I Retail Sales ❑ Medical/Dental
❑ Warehouse /Manufacturing/Distribution ❑ Restaurant/Take-Out Food
■ Will the Food Service Establishment Generate Fats, Oils Greases?. Yes[] Nq<
■ Does the Facility Have a Grease Interceptor? Yes El NoX
■ Other (describe)
For Official Use Onl
Occ Group:
Occ Group:
Occ Group:
Total Sq Ft Occu .ed:
Bldg. Permit # IA— _--0'SZ
Planning Initials: Date:
Conditions of Approval or Other Notes:
Area: �� Occ Load:
Area:�_cc Load:_
Area: Occ Load:
No. of Stories: TIF Review: Y/ N
Entitlement #: Zoning:
Building Reviewed By Initial te:
Grease Interceptor Verified Inspected By Initials: 6 Date:
South Coast
Air Quality Management District
21865 Copley Drive, Diamond Bar, CA 91765-4182
(909) 396-3529 • http:// www.agmd.gov
Air Quality Permit Checklist
California State Law Code 65850.2 prohibits cities from issuing an occupancy permit 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:
-L -
Property Address: I S I ��- l �� V1 L-0 t'1 0-/ U Z
City: HUnfinn-Foij &C 1.1(29 Zip Code:
Contact Person: N Ao*!j Title: C !�o
Type of Business: C 101-W S Telephone: 5-0 - 0000
Fax Number: e-mail addres d - co m
Applicant (print name)Ck/ -L •I/lti %�/ntpr I,S1rgnatur
Date: " / I / S� z !1
Will the facility have any of the following equipment? Yes ❑ No
�
Charbroiler
Dry cleaning machine
Spray booth
Printing press (screen/lithographic/flexographic)
Internal combustion engine greater than 50 HP (excluding motor vehicles)
Boiler/combustion equipment (greater than l 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[:] Noo
Application of paints or adhesives
Etching, plating, casting, or melting of metals
Molding, extruding, or curing of plastics
Mixing and blending of liquids and/or powders
Storage 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. If
you answered "Yes" to either question, you must contact AQMD to detennine 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 1-800-CUT-SMOG (1-800-288-7664).
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