HomeMy WebLinkAbout2270 COSMOS CT; ; CB891771; PermitBUILDING PERMIT
12/15/89 10
Page 1 of
Job Address
Permit Type
Permit No _C_B891771
09
1
2270 COSMOS CT
INDUSTRIAL TENANT
Str
IMPROVEMENT
Parcel No 213-050-42-00
Valuation 26,411
Construction Type NEW
Occupancy Group Class Code
Description 1372 SF CREATIVE NAIL DESIGN
OWNER CREATIVE NAIL DESIGN INC
2270 COSMOS CT
CARLSBAD,CA 92008
*** Fees Required *** ,. ***
Project No A8903111
Development No
Fl Ste
2065 12*15/89 0001 01 02
n-PPMT 1240-00
ISSUED
11/13/89
12/15/89
DC
Status
Applied
Apr/Issue
Validated By
.Lie 931-9770
Fees Collected & Credits ***
Fees 1,404 00
Adjustments 00
Total Fees 1,404 00
Fee description
Building Permit
Plan Check
Strong Motion Fee
Enter 'Y' to Autocalc License Tax >
* BUILDING TOTAL ,
Enter "Y" for Plumbing Issue Fee >
Enter "Y" for Electric Issue Fee >
Other . ;; >
* ELECTRICAL TOTAL ($10 Minimum)
Enter 'Y' for Mechanical . Is'sue Fee>
Each Install/Reloc Appliance Vent >
* MECHANICAL TOTAL
Total. Credits
Total Payments
Balance Due
Units Fee/Unit
10 00 /••• •••
2 00 4 50
164
1,240
00
00
00
Ext fee
265
172
4
924
1365
5
10
15
15
9
24
00
00
00
00
00
00
00
00
00
00
00
/(
Data "
Y
N
Y
REMODEL
Y
, CITY OF CARLSBAD
2075 Las Palmas Dr, Carlsbad CA 92009 (619) 438-1161
PERMIT APPLICATION
City of Carlsbad Building Department
2075 Las Palmas Or , Carlsbad, CA 92009 (619) «8-ii6i
L PERMIT TYPE I
~A O COMMERCIAL QNEU fj TENANT IMPROVEMENT
B ^INDUSTRIAL QNEW ^TENANT IMPROVEMENT
C [^RESIDENTIAL QAPARTMENT QCONDO QSINGLE FAMILY DUELLING nADOITIC"l/AI-TERAT ION
QDUPLEX noEMOLinoN QRELOCATION GMOBILE HOME DELECTRICAL QPLUMBING
QMECHANICAL OPOOL DSPA DETAINING WALL []SOLAR QOTHER
EST VAL <^- "7^ ^^P* Cs>
PLAN CK DEPOSIT /to^
VALID BY *O C-
DATE //S/''^/-3'Z?f i.
PROJECT INFORMATION PLAN CHECK No •//
1332 11/13/89 0001 01 02"
FOR OFFICE USE ONLY
Address 2270
Nearest Cross Streets
£,0tslf3.T
£ LA PlNA
Building or Suite No
LEGAL DESCRIPTION Lot No
.i.tf*
subdivision Name/Number,
^ //$&*}
CHECK BELOU IF SUBMITTED
O2 Energy Calcs 02 Structural Calcs Soils Report ] 1 Addressed Envelop:
ASSESSOR'S PARCEL
DESCRIPTION 01- UORk!
EXISTING USE PROPOSED USE
\lt>T2-04
BLDG SO FTG * OF STORIES
3 CONTACT PERSON
ADDRESS
STATE .* ZIP CODE
SIGNATURE /^ JSsfw ' ^JfiZi^TTTZtsytS!!
4
5
6
7
APPI Tf*AI/T " "*" rnT-nVro^rTnDrtir^iWr^MI . |] LUW ltW\L t UKNAME TTf^M/H w&fZp'rrlZc?!^
CITY £&KL4&rtC>
PROPERTY OWNER t _
NAME £,fZ.&arT-u/£. NAIL. l/&yl<&
CITY £-AfZ.i.'Z>&^£'
CONTRACTOR
NAME
CITY
STATE LIC n
SIGNATURE
DESIGNER NAME
CITY
WORKERS' COMPENSATION
//D AGENT
t/
STATE <
OWNER
//, INo,
STATE ^
STATE
STATE
FOR CONTRACTOR DOWNER
ADDRESS 2-2T~C> £•&
(Z-A ZIP CODE ^"llff^B^
ADDRESS "2.'2.~7£? &•£
£rf ZIP CODc *$ '%#&£'
ADDRESS
ZIP CODE
LICENSE CLASS
TITLE
ADDRESS
ZIP CODE
C] AGENT FOR OWNER
«7t^e>4 £-&MFS.T
DAY TELEPHONE l"^ 1 - ^TJ ^
SLESSEE Q TENANT
^M 0 S> tZtSH f?.T
DAY TELEPHONE *?^/-^77^
DAY TELEPHONE
CITY BUSINESS LIC #
DATE
DAY TELEPHONE STATE LIC #
Workers Compensation Declaration I hereby affirm that 1 have a certificate of consent to self insure issued by the Director of Industrial Relations
or a certificate of Workers Compensation Insurance by an admitted insurer or an exact copy or duplicate thereof certified by the Director of the
insurer thereof filed with the Building Inspection Department (Section 3800 Lab C)
INSURANCE COMPANY POLICY NO EXPIRATION DATE
Certificate of Exemption I certify that in the performance of the work for which this permit is issued I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws of California
SIGNATURE DATE
8 OWNER-BUILDER DECLARATION
Owner Builder Declaration I hereby affirm that I am exempt from the Contractor s License Law for the following reason
Q 1 as owner of the property or my employees with wages ns their sole compensation will do the work and the structure is not intended or offered for sale
(Sec 7044 Business and Professions Code The Contractor s License Law does not apply to an own-T of property who builds or improves thereon and who
does such work himself or through his own employees provided that such improvements are not iniended or offered for sale If however the building
or improvement is sold within one year of completion the owner builder will have the burden of proving that he did not build or improve for the purpose
of sale )
O I as owner of the property am exclusively contracting with licensed contractors to construct the project (Sec 7044 Business and Professions Code
The Contractor s License Law does not apply to an owner of property who builds or improves thereDn and contracts for such projects with contractor(s)
licensed pursuant to the Contractor s License Law)
I am exempt under Section Business and Professions Code for this rca on
SIGNATURE DATE
COMPLETE THIS SECTION FOR NON RESIDENTIAL BUILDING PERMITS ONLY
Is the applicant or future building occupant required to submit a business plan acutely hazardous mat rials registration form or risk management and prevention
program under Sections 25505 25533 or 25534 of the Presley Tanner Hazardous Substance Account Act'
DYES DNO
Is the applicant or future building occupant required to obtain a permit from the air pollution control district or air quality management district'
DYES DNO
Is the facility to be constructed within 1 000 feet of the outer boundary of a school site7
DYES QNO
IF ANT OF THE ANSWERS ARE YES A FINAL CERTIFICATE OF OCCUPANCY MAT NOT BE ISSUED AFTER JULY 1 1989 UNLESS THE APPLICANT HAS KET OR IS MEETING THE REQUIREMENTSOF THE OFFICE OF EMERGENCY SERVICES AND THE AIR POLLUTION CONTROL DISTRICT
i CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097(1) Civil Code)
LENDER'S NAME LENDER S ADDRESS
10 APPLICANT'S SIGNATURE
I certify that I have read the application and state that the above information is correct I agree tc conoly witn all City ordinances and State laws relating
to building construction I hereby authorize representatives of the City of Carlsbad to enter upon the :ibove mentioned property fo~ inspection purposes 1 ALSO
AGREE TO SAVE INDEMNIFY AND KEEP HARMLESS THE CITY OF CARLSBAD AGAINST ALL LIABILITIES JUDGMENTS COSTS AND EXPENSES UHICH MAY IN ANY WAY ACCRUE AGAINST SAID
CITY IN CONSEQUENCE OF THE GRANTING OF THIS PERMIT
Expiration Every permit issued by the Building Official under the provisions of this Code shall expire by limitation and become null and void if the building
or work authorized by such permit is not commenced within 180 days from the date of such permit or if the building or work authorized by such permit is suspended
or abandoned at any time after the work is commenced for a period of 180 days (Section 303(d) Uniform Building Code)
APPLICANT? SIGN^URE OWNER L7] CONTRACTOR PHONE APPROVED BY
DATE
^
HITE pile YELLOW Applicant PINK Finance
RNAL BUILD.NG INSPECr.ON RECEIVED JAW 1 6
PLAN CHECK NUMBER DATE *"*3'
PROJECT NAME Cfoativa N
ADDRESS 2270 Coonos Ct
PROJECT NO UNIT NUMBER PHASE NO
CTITYPE OF UNIT NUMBER OF UNITS
CONTACT PERSON "U~
CONTACT TELEPHONE ""*
COMMENTS
DATE , .
INSPECTED '/ (I I ff^ APPF1OVED X DISAPPROVED
INSPECTED DATE
BY INSPECTED APPROVED DISAPPROVED
INSPECTED DATE
BY INSPECTED APPROVED DISAPPROVED
Rev 1/86 WHITE Suspense BLUE Water District GREEN Engineering CANARY Utilities PINK Planning GOLD Fire
PERMIT* CB891771
DESCRIPTION 1372
CITY OF CARLSBAD
INSPECTION REQUEST
FOR 01/12/90
SF CREATIVE NAIL DESIGN
TYPE ITI
JOB ADDRESS
APPLICANT:
CONTRACTOR.
OWNER:
2270 COSMOS
YOUNG, RICHARD
CT
CREATIVE NAIL DESIGN INC
PHONE i
PHONE:
PHONE:
STR: FL:
619 941-4647
931-9770
INSPECTOR AREA MC
PLANCK* CB891771
OCC GRP
CONSTR TYPE NEW
STE:
REMARKS' T2/MH/MARK/758-714afg31-9770
SPECIAL INSTRUCT. AM IF POSSIBLE
INSPECTOR
TOTAL TIME:
CD LVL DESCRIPTION ACT COMMENTS
19
29
39
49
ST Final Structural
PL Final Plumbing
EL Final Electrical
ME Final Mechanical
***** INSPECTION HISTORY *****
DATE DESCRIPTION
010990 Final Structural
010990 Final Electrical
122289 Interior Lath/Drywall
122189 Frame/Steel/Bolting/Welding
122189 Rough Electric
ACT INSP COMMENTS
CO MPC NDS R.A. IN OFFICES
CO MPC NDS SEISMIC SUPPORTS/FIXTURES
AP MPC
AP MPC WALLS
AP MPC WALLS
ESGIL CORPORATION
932O CHESAPEAKE DR , SUlTEi 2O8
SAN DIEGO, CA 92123
(619) 56O-1468
n
^
DATE.
JURISDICTION
PLAN CHECK NO.SET
PROJECT ADDRESS 2 1 1 0
PROJECT NAME .O O g
Q^PBLJLCANT^
jPLAN CHECKER
_]FILE COPY
QUPS
HDESIGNER
D
D
The plans transmitted herewith have been corrected where
necessary and substantially comply with the jurisdiction's
building codes.
The plans transmitted herewith will substantially comply
with the jurisdiction's building codes when minor deficien-
cies identified are resolved and
checked by building department staff
The plans transmitted herewith have significant deficiencies
identified on the enclosed check list and should be corrected
and resubmitted for a complete recheck.
The check list transmitted herewith is for your information
The plans are being held at Esgil Corp. until corrected
plans are submitted for recheck.
The applicant's copy of the erect list is enclosed for the
jurisdiction to return to the applicant contact person
The applicant's copy of the check list has been sent to
Esgil staff did not advise the applicant contact person that
— plan check has been completed. .j f
II Esgil staff did advise applicant that the plan check has
— been completed Person contacted-
Date contacted:
(| REMARKS:
Telephone #
By:
ESGIL CORPORATION
DGA DAA Dvw QDM
Enclosures
Datei Jurisdiction
Prepared by i
VALUATION AND PLAN CHECK
n Bldg. Dept,
D Esgil
PLAN CHECK NO.
BUILDING ADDRESS 2. "2. TO £o SWIPES
APPLICANT/CONTACT
BUILDING OCCUPANCY
TYPE OF CONSTRUCTION V—
PHONE NO.A-l
DESIGNER PHONE
CONTRACTOR PHONE
BUILDING PORTION
OPA T.I,
Air Conditioning
Commercial
Residential
Res. or Comm.
Fire Sprinklers
Total Value
BUILDING AREA
1^-7^ Cr
VALUATION
MULTIPLIER
^ \°>zs
@
§
@
VALUE
- ££;4Ui
2<S,4-I»
Building Permit Fee $
Plan Check Tee $
COMMENTS.
SHEET OF
12/87
BUILDING PLANCHECK
ENGINEERING CHECKLIST
DATE ///W0? 0 ITEM COMPLETE
PLANCHECK NO B^lHI O ITEM INCOMPLETE -
NEEDS YOUR ACTION
X ITEM SELECTED
1s
T
C
H
E
C
2
N
D
C
H
E
C
/K
3
R
D
C
H
E
C
K
^27O LtoSws C 7"
PROJECT ID
LEGAL REQUIREMENTS
Site Plan
1 Provide a fully dimensioned si plan drawn to scale Show
north arrow, property lines, easements, existing and proposed
structures, streets, existing street improvements, right-of-
way width and dimensioned setbacks
' •—' 2 Show on site plan Finish floor elevations, pad elevations,
elevations of finish grade adjacent to building, existing
topographical lines, existing and proposed slopes, driveway
with percent (%) grade and drainage patterns
'—' '—' 3 Provide legal description and Assessors Parcel Number
Discretionary Approval Compliance
X 4 No Discretionary approvals were required
Project complies with all Engineering Conditions of Approval
for Project No
Project does not comply with the following Engineering
Conditions of Approval for Project No
Conditions complied with by Date
Field Review
7 Field review completed No issues raised
8 Field Review completed The following issues or discrepancies
with the site plan were found
A Site lacks adequate public improvements
B Existing drainage improvements not shown or in conflict
with site plan
C Site is served by overhead power lines
D Grading is required to access site, create pad or provide
for ultimate street improvement
FRM0010 DH 08/29/89
I Site access visibility problems exist Provide onsite
turnaround or engineered solution to problem
Other
Dedication Requirements
A. 9 No dedication required
.10 Dedication required Please have a registered Civil Engineer
or Land Surveyor prepare the appropriate legal description
together with an 8V' x 11" plat map and submit with a title
report and the required processing fee All easement documents
must be approved and signed by owner(s) prior to issuance of
Building Permit The description of the dedication is as
follows
Dedication completed, Date By
Improvement Requirements
11 No public improvements required SPECIAL NOTE Damaged or
defective improvements found ad.iacent to building site must
be repaired to the satisfaction of the City inspector prior
to occupancy
12 Public improvements required This project requires
construction of public improvements pursuant to Section 18 40
of the City Code Please have a registered Civil Engineer
prepare appropriate improvement plans and submit for separate
plancheck process through the Engineering Department
Improvement plans must be approved, appropriate securities
posted and fees paid prior to issuance of permit The required
improvements are __
Improvement plans signed, Date By
FRM0010 DH 08/29/89
13 Improvements are required Construction of the public
improvements may be deferred in accordance with Section 18 40
of the City Code Please submit a letter requesting deferral
of the required improvements together with a recent title
report on the property and the appropriate processing fee so
we may prepare the necessary Future Improvement Agreement
The Future Improvement Agreement must be signed, notarized and
approved by the City prior to issuance of a Building Permit
Future Improvement Agreement completed, Date
By
Grading Requirements
13a Inadequate information available on site plan to make a
determination on grading requirements Please provide more
detailed proposed and existing elevations and contours
Include accurate estimates of the grading quantities (cut,
fill, import, export)
yv^!4 No grading required as determined by the information provided
on the site plan
15 Grading Permit required A separate grading plan prepared by
a registered Civil Engineer must be submitted for separate
plan check and approval through the Engineering Department
NOTE The Grading Permit must be issued and grading
substantially complete and found acceptable to the City
Inspector prior to issuance of Building Permits
Grading Inspector sign off Date By
Miscellaneous Permits
X 16 Right-of-Way Permit not required
17 Right-of-Way Permit required A separate Right-of-Way Permit
issued by the Engineering Department is required for the
following
X 18 Sewer Permit is not required
19 Sewer Permit is required A Sewer Permit is required
concurrent with Building Permit issuance The fee required
is noted below in the fees section.
20 Industrial Waste Permit is not required
FRM0010 DH 08/29/89
.21 Industrial Waste Permit is required Applicant must complete
Industrial Waste Permit Applicantion Form and submit for City
approval prior to issuance of Building Permits Permits must
be issued prior to occupancy
Industrial Waste Permit accepted -
Date By
Fees Required
_22 Park-in-Lieu Fee
Quadrant Fee per Unit "' Total Fee
A 23 Traffic Impact Fee
Fee Per Unit ~~ ~ "" Total Fee
24 Bridge and Thoroughfare Fee
Fee per Unit Total Fee
j Public Facilities Fee required
26 Facilities Management Fee Zone -±> Fee
27 Sewer Fees/, Permit No EDU's
Fee
28 Sewer Lateral required
Fee _
REMARKS
ENGINEERING AUTHORIZATION TO ISSUE PERMIT
Date
FRM0010 DH 08/29/89
HIna
PLANNING CHECKLIST
Plan Check No
APN ^'«3 -O
PI anner
•*J-Address
Phone 438-1161
(Name)
Type of Project and Use
Zone Facilities Management Zone
Legend
Item Complete
Item Incomplete - Needs your action
1, 2, 3 Number in circle indicates plancheck number that deficiency
was identified
Environmental Review Required
DATE OF COMPLETION
YES NO TYPE
Compliance with conditions of approval' If not, state conditions which
require action
Conditions of Approval
Discretionary Action Required YES
APPROVAL/RESO NO
PROJECT NO
NO
DATE
TYPE
OTHER RELATED CASES
Compliance with conditions of approval' If not, state conditions which
require action
Conditions of Approval
IDO Coastal YES NO DATE OF APPROVAL
Compliance with conditions of approval7 If not, state conditions which
require action
Conditions of Approval
D Landscape Plan Required YES _ NO X
See attached submittal requirements for landscape plans
Site Plan
fj 1 Provide a fully dimensioned site plan drawn to scale Show
North arrow, property lines, easements, existing and proposed
structures, streets, existing street improvements, right-of-way
width and dimensioned setbacks
[] 2 Show on Site Plan Finish floor elevations, elevations of finish
grade adjacent to building, existing topographical lines, existing
and proposed slopes and driveway
QQ [J] 3 Provide legal description of property
QQ r-) 4 Provide assessor's parcel number
Zoning
DO 0 1 Setbacks
Front Required Shown
Int Side Required Shown
Street Side- Required Shown
Rear Required Shown
a a a 2 Lot coverage Required Shown
COO 3 Height Required Shown
CO O 4 Parking Spaces Required Shown
Guest Spaces Required Shown
Additional comments and remarks have been nade on the building plans These
marked-up plans may be picked up at the Building Department. These marked-
up plans must be resubmitted with the revised plans for this project.
Have plans been marked up' YES NO
Additional Comments
OK TO 1SSUE DATE'
PLNCK FRM
2560 ORION WAY Cttp of Cartebato _.__. nF /
CARLSBAD, CA 92008 p/fl£ DEPARTM£NT °F ~T
TELEPHONE
(619) 931 2121
DISAPPROVED
PLAN CHECK REPORT
APPROVED
PLAN CHECK#
69 -/77/
c" AJAiC &£$/&*.', 3)jr ADDRESS 23 ~7T)rt>S*n c?S, £7"
ARCHITECT Vnu AJfa /£ 6/ MS /)fc7t> /9-P^ ADDRESS I^L-L £i2 rtnt<. PHONE "7o? 8 - &<b/
OWNER (^tfty^TlUZ: A/A'*- .L&s/£>*<S-n'C. ADDRESS /^iff iS/2)^^) PHONE
"rVOV /-/ T- CONST HZ A/ TOTAL SQ FT r9 9, £y p STORIES ^? 3/-977<l)
NB SPRINKLERED M-TENANT IMP ',3"?X SrvFf
APPROVAL OF PLANS IS PREDICATED ON CONFORMING
TO THE FOLLOWING CONDITIONS AND/OR MAKING
THE FOLLOWING CORRECTIONS
PLANS, SPECIFICATIONS, AND PERMITS
1 Provide one copy of floor plan(s), site plan, sheets ____^_
2 Provide two site plans showing the location of all existing fire hydrants within 200 feet of the project
3 Provide specifications for the following
4 Permits are required for the installation of all fire protection systems (sprinklers, stand pipes, dry chemical, halon,
CO2, alarms, hydrants) Plan must be approved by the fire department prior to installation
5 The business owner shall complete a building information letter and return it to the fire department
FIRE PROTECTION SYSTEMS AND EQUIPMENT
6 The following fire protection systems are required _
siS Automatic fire sprinklers (Design Criteria ^5^ rc^'L A/ F'~i?A / ±> )
D Dry Chemical, Halon, COz (Location )
D Stand Pipes (Type )
D Fire Alarm (Type/Location )
7 Fire Extinguisher Requirements /•
.M3_One 2A rated ABC extinguisher for each _L£r!Q£lOsq ft or portion thereof with a travel distance to the nearestrextinguisher not to exceed 75, feejof travel
D An extinguisher with a minimum rating of to be located
D Other
8 Additional fire hydrant(s) shall be provided
EXITS
9 Exit doors shall be openable from the inside without the use of a key or any special knowledge or effort
10 A sign stating, " This door to remain unlocked during business hours shall be placed above the mam exit and
doors
11 EXIT signs (6" x 3A" letters) shall be placed over all required exilts and directional signs located as necessary to
clearly indicate the location of exit doors
GENERAL
2 Storage, dispensing or use of any flammable or combustible liquids, flammable liquids, flammable gases and
hazardous chemicals shall comply with Uniform Fire Code
13 Buildmg(s) not approved for high piled combustible stock Storage in closely packed piles shall not exceed 15 feet
in height, 12 feet on pallets or in racks and 6 feet for tires, plastics and some flammable liquids If high stock pil
ing is to be done, comply with Uniform Fire Code, Article 81
.14 Additional Requirements
C i lM & VOu
.15 Comply with regulations on attached sheet(s)
Plan Fvsmin../ - ^4— r^<£2--t-^— ~.-,Tt
Report mailed to architect _ Met with __ ; _ _ Attach to Plans
Plan Fvsmin../ - ^4— r^<£2--t-^— ~.-,T __ Date _ ///2 2 / r*TSt /
\
City of Carlsbad•^ nfnfwM^i^Li^j^*pgMM3u»^i!Bi^Mi>^*""**"'"*^^DeDartment
DATE -y
Chris Smith
ENCINA WATER POLLUTION CONTROL FACILITIES
6200 Avenida Enemas
Carlsbad, CA 92009
INDUSTRIAL WASTE PERMIT APPLICATION NO
Enclosed is a copy of the application for an Industrial Waste Discharge Permit from
the subject applicant
Your review and recommendations on this application will be appreciated prior to
the issuance of a waste disposal permit
Fb<z LLOYD B HUBBS
City Engineer
LBH SEE Ich
,); ? Enclosure Application No
,8 Department ,.; ,. \ V i , ,
[|J* jt^i'iii'f • "' i Efniei1 Ferrer, Deipartrhent of Public Works
,' Arnie Wing, Department of Health Services
2075 Las Palmas Drive • Carlsbad California 92009-4859 • (619)438-1161
COMMERCIAL/INDUSTRIAL
APPLICATION FORM FOR INDUSTRIAL WASTE DISCHARGE PERMIT
CITY OF CARLSBAD
APPLICATION. NEW
(CHECK ONE) REVISED
BUILDING P.C. NO.
APPLICATION NO.
INDUSTRIAL CLASS;
DATE;
Signature of City Representative
APPLICATION FOR INDUSTRIAL WASTE DISCHARGE PERMIT
A. GENERAL
APPL ICANT / J&ADDRESS!
TYPE OF BUSINESS;t/^e, A4,/
APPLICANT'S ADORE5S;
B. WASTES AND PROCESSING: (Check where applicable)
Domestic Waste Only Industrial Waste |~| Industrial Waste NOT
Discharged to Sewer Discharged to Sewer
GENERAL DESCRIPTION OF WASTE (Chemical and Physical Characteristics of
proposed waste). __ '_
GENERAL DESCRIPTION OF PROCESS (If Applicable)
C. WASTES TO-fiE DISCHARGED TO SEWER:
WASTE.TREATED;
(Check One) UNTREATETT _
/
QUANTITY- AVERAGE
(Daily) MAXIMUM
GPD
GPD
(Gallons Per Day)
lfM 3vl;;!i:i:L r-
^» ..... f
APPLICANT. OR REPRESENTATIVE OF FIRM;
TITLE
(Print
SIGNATURE;DATE J/~ /?>-'>-