HomeMy WebLinkAbout2880 PIO PICO DR; 103; CB911496; PermitB U I L D I N G P E R N I T Permit No: CB911496
11/15/91 11:16
Page 1 o 1
Job Address: 2890 PlO PICO DR
Permit Type: INDUSTRIAL TENANT IMPROVEMENT
Parcel No: 156-164-57-00
Valuation:' 51,093
Construction Type: VN
Occupancy Group: B2 Class Code:
Description: 2433 SF OFFICE REMODEL FOR
BRYAN PHOTO
Appl/Ownr : BRYAN, GERALD
2880 PlO PICO
CARLSBAD, CA 9200
Project No: A9101895
Development No:
Str: ** Fl: **** Ste: 103
5267 11115/91 0001 01 02
- C-PRMT 2243.00
flr
Status: ISSUED
Applied: 11/04/91
Apr/Issue: 11/15/91
Validated By: MC
619 434-3318
CONTRACTOR :.MULLEN, EDGAR/
2890 PlO PI-TO 7
CARLSBAD, A92
Fees Required F
Adjustments: / Total Fees: 2,0 ay
Strong
B, anc
Fee description nits
Building Permit
Plan Check
-----------
---
.00
276.00,
2,243.001,
Ext fee Data
/ 424.00
/ 276.00
11.00
Enter Y" to Autocal\Li-930.00 Y - x1s 'X ?NCORPORATED 858.00ErrD-0 1952 _ I"
* BUILDING TOTAL \f / 2499.00
Enter "Y"
Enter "Y" : Electric Issue Fe~ie
*
Enter "Y" for Remodel
ELECTRICAL TOTAL
Enter 'Y' for Mechanical Issue Fee>
!SPc1I'
çPPROVAL
DATE______
CITY OF CARLSBAD
2075 Las Palmas Dr., Carlsbad, CA 92009 (619) 438-1161
619 434-21233
Ile-c-e & Credits
c)r'
N
10.00 Y
10.0.0 Y
20.00
N
PERMIT APPLICATION
City of Carlsbad Building Department
2075 Las Palmas Dr., Carlsbad, CA 92009 (619) 438-1161
I. PERMIT TYPE
A - U Commercial U New Building U Tenant Improvement
B - 0 Industrial a New Building 0 Tenant Improvement
C - 0 Residential 0 Apartment 0 Condo 0 Single Family Dwelling 0 Addition/Alteration
Duplex 0 Demolition 0 Relocation Li Mobile Home a Electrical D Plumbing
0 Mechanical 0 Pool 0 Spa a Retaining Wall 0 Solar 0 Other__________
PLAN CHECK NO. q/
5099 11/04/91 0001 01 02 FOR OFFICE P.1LY 276.00
0 I'M
Nearest Cross Street
LEGAL DESCRIPTION Lot No. Subdivision Name/Number Unit No. Phase No.
CHECK BELOW IF SUBMIITED:
02 Energy Calcs 02 Structural Calcs 02 Soils Report 131 Addressed Envelope
ASSESSOR'S PARCEL EXISTING USE PROPOSED USE
DEyIPTION OF WORK / - (irip gc,q.. (.
Fr. o Y33 # OF STORIES f 2f,4 c7rc)
NAME ADDRESS
CITY STATE ZIP CODE DAY TELEPHONE
APPUGArfr U CONTRACTOR Li AGENT FOR CON ITRADUR Li OWNER Li AGENT FOR OWNER
NAME / ADDRESS
CITY STATE ZIP CODE DAY TELEPHONE
PROPERTY OWNER /'ji ,t7c2 NAME ej- v%q T.r L.LOJL) ADDRESS OW
zmCoricb d U STATE ZIP CODE DAY TELEPHONE 0. L"14 1jjA.LIJK
ADDRESS e8 P4 ItIl'CO NAME r C ZIP CODE DAY TELEPHONE CITY ( r /$boI/"- STATE
STATE UC. # LICENSE CLASS CITY BUSINESS UC. # Xke'ø!S #6Ue 1/
DESIGNER NAME ADDRESS
CITY STATE ZIP CODE DAY TELEPHONE STATE LIC. #
WORKERS' WMPENSAI1ON
Workers' Compensation Declaration: I hereby affirm that I have a certificate of consent to sell-insure issued by the Director of IndustnaI
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. Q.
INSURANCE COMPANY POLICY NO. EXPIRATION DATE
Certificate of Exemption: I certily that in the performance 01 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
OWNER-BUILDER DECLARATION
Owner-Builder Declaration: I hereby affirm that I am exempt from the Contractor's License Law for the following reason:
I, as owner of the property or my employees with wages as 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 owner of property who builds
or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended
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.).
1, 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 thereon, 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 reason:
(Sec. 7031.5 Business and Professions Code: Any City or County which requires a permit to construct, alter, improve, demolish, or repair
any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the
provisions of the Contractor's License Law (Chapter 9, commencing with Section 7000 of Division 3 of the Business and Professions Code)
or that he is exempt therefrom, and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars [$500]).
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 materials registration form or risk management and
prevention program under Sections 25505, 25533 or 25534 of the Presley-Tanner Hazardous Substance Account Act?
DYES ONO
Is the applicant or future building occupant required to obtain a permit from the air pollution control district or air quality management district?
DYES ONO
Is the facility to be constructed within 1,000 feet of the outer boundary of a school site?
DYES 0 N
IF ANY OF THE ANSWERS ARE YES, A FINAL CERTIFICATE OF OCCUPANCY MAY NOT BE ISSUED AFIR JULY 1, 1989 UNLESS THE APPLICANT
HAS MET OR IS MEETING THE REQUIREMENTS OF fliE OFFICE OF EMERGENCY SERVICES AND THE AIR POLLUTION CONTROL DISThICF.
ereDy affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097(i) Civil Code).
LENDER'S NAME LENDER'S ADDRESS
10. APPLICANT CERTIFICATION
I certify that I have read the application and state that the above information is correct. I agree to comply with all City ordinances and State laws
relating to building construction. I hereby authorize representatives of the City of Carlsbad to enter upon the above mentioned property for inspection
purposes. I ALSO AGREE 10 SAVE INDEMNIFY AND KEEP HARMLESS THE CITY OF CARLSBAD AGAINST ALL LIABILITIES, JUDGMENTS, (TISTS
AND EXPENSES WHICH MAY IN ANY WAY ACCRUE AGAINST SAID CITY IN CONSEQUENCE OF THE GRANTING OF ThIS PERMIT.
051-1k An OSHA permit is required for excavations over 5'O" deep and demolition or construction of structures over 3 stories in height.
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 365 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 1BuJ)ing Code).
çsIG // DATE:"/ 7/1/
CITY OF CARLSBAD.
INSPECTION REQUEST
iMIT# CB911496 FOR 12/23/91 INSPECTOR AREA PD
CRIPTION: 2433 SF OFFICE REMODEL FOR PLkNCK# CB911496
BRYAN PHOTO .0CC GRP
E: ITI CONSTR. TYPE NEW
ADDRESS: 2890 PlO PICO DR STR:** FL:**** STE: 103
PLICANT: BRYAN, GERALD PHONE: 619 434-3218
NTRACTOR: MULLEN, EDGAR PHONE: 619 434 233
NER: PHONE:
MARKS: MH/ED/434-2233 INSPECTOR
?ECIAL INSTRUCT: DID NOT SAY WHAT TYPE OF INSPECTION
AL TIME:
LVL DESCRIPTION ACT COMMENTS
9 ST Final Structural
9 PL Final Plumbing
9 EL Final Electrical
9 ME Final Mechanical
***** INSPECTION HISTORY *****
DATE DESCRIPTION
112191 Interior Lath/Drywall
112 091 Frame/Steel/Bolting/Welding
112091 Rough Electric
112 091 Frame/Steel/Bolting/Welding
112091 Rough Electric
111891 Frame/Steel/Bolting/Welding
111891 Rough Electric
ACT INSP
AP PD
NS PD
NS PD
AP PK
AP PK
CO PD
CO PD
COMMENTS
RECEIVED L: 2 Li 991
FINAL BUILDING INSPECTION
DEPT: BUILDING ENGINEERING PLANNING U/N WATER
PLAN CHECK#: CB911496 DATE: 12/23/91
PERNIT#: CB911496 PERMIT TYPE: ITI
PROJECT NAME: 2433 SF OFFICE REMODEL FOR
BRYAN PHOTO
ADDRESS: DRSUITE# 1Q3.iJ
CONTACT PERSON/PHONE#: MH/ED/434-2233
SEWER DIST: CA WATER DIST: CA
INSPECTED, DATE
BY: INSPECTED: r/Le /q. APPROVED K, DISAPPROVED
INSPECTED DATE
BY: INSPECTED: APPROVED DISAPPROVED
INSPECTED DATE
BY: INSPECTED: APPROVED DISAPPROVED
COMMENTS:
MULLEN
CONSTRUCTION
WHEN ONLY THE BEST WILL DO
H 4mt 4)9114. /A)/26' 1W 5'I2,o
L2)
L"1h-
(__3) /a6PI a4l.:F r---r i'',"o
We kici4'
#421785 • 2890 Plo Pico P.O. Box 1480 Cérlsbad, CA 92018-1480 • (619) 434-2233 FAX 434-4817
ESGIL CORPORATION
9320 CHESAPEAKE DR., SUITE 208
SAN DIEGO, CA 92123
(619) 560-1468
DATE:
JURISDICTION: ?,
PLAN CHECK NO: S\- 4-) C,SET:
PROJECT ADDRESS: ADDRESS:
PROJECT NAME:
JURISDICTION
FILE COPY
UPS
DESIGNER
r//11 The plans transmitted herewith have been corrected where
necessary and substantially comply with the jurisdiction's
building codes.
fl 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 .eciosed check list and should be corrected
and resubmitted for a comp-lete recheck.
o 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 check 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.
[1 Esgil staff did advise applicant that
been completed. Person contacted:_
the plan check has
Date contacted: Telephone #
REMARKS:
By: Enclosures:_______
ESGIL CORPORATION
EGA 0dM
4
Date 1 Jurisdiction Ci'2sc0
Prepared byi
D Bldg. Dept.
VALUATION AND PLAN CHECK FEE 0 Esgil
PLAN CHECK NO. -
BUILDING ADDRESS - o io
APPLICANT/CONTACT 'R-? RY1 PHONE NO. 434
BUILDING OCCUPANCY '-2 (Jr1 DESIGNER PHONE
TYPE OF CONSTRUCTION CONTRACTOR PHONE__________
1<
BUILDING PORTION BUILDING AREA VALUATION
MULTIPLIER
VALUE
—A ir Conditionthe
Commercial
Residential
-
Res. or Comm.
Fire Sprinklers
Total Value
Building Permit Fee $_
ET 1E
Plan Check Fee $ $
COM MENTS:
1
SHEET OF
12/87
- UI BUILDING PLANCHECK
Q ENGINEERING CHECKLIST
DATE:t I '1 I
S
ZITEM COMPLETE
UJ PLANCHECK NO.t2 IL1 ITEM INCOMPLETE
tii NEEDS YOUR-ACTION
1 2 3 Z?O Plo Pô T)rRJe. ITEM SELECTED
S N R.
T D D
C C C PROJECT ID:APr\ IS- I( 57
H H H
E E E LEGAL REQUIREMENTS
K K K, Site Plan
Provide a fully dimensioned sie plan drawn to scale.
Show: north arrow, property lines, easements, existing and
proposed structures, streets, existing street improvements,
dF~
right-of-way width and dimension setbacks.
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.
E E 3. Provide legal description and Assessors Parcel Number.
/ Discretionary Approval Compliance
4. No Discretionary appro'ials were required.
LI LI LI 5 . Project complies with all Engineering Conditions of
Approval for Project No.________________
LI LI LI 6. Project 'does not comply with the following Engineering
Conditions of Approval for Project No.__________________
Conditions complied with by: Date:________
Field Review
LI LI 7. Field review completed. No issues 'raised.
LI LI LI 8. Field review completed. The following issues or
discrepancies with the site plan were found:
LI LI] LI A. Site lacks adequate public improvements
LI LI LI B. Existing drainage. 'improvements not shown or in
conflict with site plan.
LI LI LI C. Site is served by overhead power lines.
P:\D0CS\MISF0RI4S\FRM0010.DH REV. 02/27/91
r D. Grading is required to access site, create pad or
provide for ultimate street improvement.
E EIE E. Site access visibility problems exist. Provide onsite
turnaround or engineered solution to problem.
El 00 F. Other:____________________________________________
Dedication Requirements
9. No dedication required.
LII E E 10. Dedication required. Please have a registered Civil
Engineer or Land Surveyor prepare the appropriate legal
description together with an 8k" 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:
inprovement Requirements
11. No public improvements required. SPECIAL NOTE: Damaged or
defective improvements found adjacent 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:
P:\D0CS\MISF0RMS\FRI40010.DH REV. 02/27/91
E 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:
El 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).
r-A'
LLJ
r
14. No grading required as determined by the information
provided on the site plan.
F-100 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
aradina substantially complete and found acceptable to the
City Inspector prior to issuance of Building Permits.
Grading Inspector sign off. Date: by:
Miscellaneous Permits
16. Right-of-Way Permit not required.
EEl El 17. Right-of-Way Permit required. A separate Right-of-Way
Permit issued by the Engineering Department is required for
the following:
J12/1 E~ 18. Sewer Permit is not required.
El El El 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.
El El El 20. Industrial Waste Permit is not required.
P:\DOCS\MISFORMS\FRMOO1O.DH REV. 02/27/91
21. Industrial Waste Permit is required. Applicant must
complete Industrial Waste Permit Application Form and
submit for City approval prior to issuance of a Building
Permits. Permits must be issued prior to occupancy.
Industrial Waster Permit accepted -
Date: _I/i4g I By:________________
Fees Required
O 27. Park-in-Lieu Fee
Quadrant: Fee per Unit:
Total Fees:_____
El 23. Traffic Impact Fee
Fee Per Unit:_____ Total Fee:
C] 24. Bridge and Thorough fare Fee
Fee Per Unit:______________ Total Fee:
0
D
0
1,3
Public Facilities Fee required.
Facilities Management Fee Zone: Fee:________
Sewer Fees Permit No. EDU's -
Benefit Area: Fee:
Sewer Lateral Required:
Fee:
29; REMARKS: _t'JEt COMPLETE A )t.JDUSTtJAL
\,JisTE PERiT APPuc.ATtO'J ?LE'\SE.
As. FO(. ME (MRr,' Aut3 Ln-J
suMTr3(r- APPL.C-AflOtJ..
ENGINEERING AUTHORIZATION TO ISSUE PERMIT
BY DATE
P:\D0CS\MISF0RMS\FRM0010.DH REV. 02/27/91
PLANNING CHECKLIST
Plan Check No. 9/-'Y6 Address Z' W ,lo Pe'cO
Planner I)A,J ,iicL Phone 438-1161 ext.
H
(Name) I.
APN:
IL
__________ Type of Project and Use . OW c-6 Z
Zone / F- 2 Facilities Management Zone
A
-3
I
II
_ Legend
.- J I•
. .' a U o 0 4 W J Item Complete .c .0 .0 U 0 0
C C Cco
0 Item Incomplete - Needs your action
1, 2, 3 Number in circle indicates plancheck number where deficiency was
identified
D 0 Environmental Review Required: YES - NO & TYPE
DATE OF COMPLETION:
Compliance with conditions of approval? If not, state conditions which require action.
Conditions of Approval
or 0 El Discretionary Action Required: YES - NO TYPE
APPROVALJRESO. NO. - DATE:
PROJECT NO.
OTHER RELATED CASES: -
Compliance with conditions of approval? If not, state conditions which require action.
Conditions of Approval
California Coastal Commission Permit Required: YES - NO
DATE OF APPROVAL:
San Diego Coast District, 3111 Camino Del Rio North, Suite 200, San Diego, CA. 92108-1725
(619) 521-8036
Compliance with conditions of approval? If not, state conditions which require action.
Conditions of Approval
Zoning:
71600 c,
1. Setbacks:
Front:
Int. Side:
Street Side:
Rear:
Lot coverage:
Height:
Parking:
0 Landscape Plan Required: YES NO >
"Sm
Wo
See attached submittal requirements for landscape plans
Site Plan:
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.
Show on Site Plan: Finish floor elevations, elevations of finish grade
adjacent to building, existing topographical lines, existing and proposed
slopes and driveway.
51
Provide legal description of property.
Provide assessor's parcel number.
Required Shown -
Required Shown.
Required Shown.
Required Shown.
Required Shown.
Required Shown
Spaces Required Shown
Guest Spaces Required Shown
0 0 0 Additional Comments
OK TO ISSUE AND ENTERED APPROVAL INTO COMPUTER V46v DATE
PLNCK.FRM
2560 ORION WAY
CARLSBAD, CA 92008
TELEPHONE
(619) 931-2121
(Citp of (artbab
FIRE DEPARTMENT
PLAN CHECK REPORT
PAGE 1 OF
APPROVE7,
DISAPPROVED
PLAN CHECK#
PROJECT _____ 04 ADDRESS ,479() 2ô 'i—I C,
ARCHITECT ADDRESS 'Tk PHONE59 F -
OWNER ADDRESS PHONE
OCCUPANCY 7i\J CONST. TOTAL SQ. FT. STORIES
JRI N KLER ED ENANT IMP.
APPROVAL OF PLANS IS PREDICATED ON CONFORMING
TO THE FOLLOWING CONDITIONS AND/OR MAKING
THE FOLLOWING CORRECTIONS:
PLANS, SPECIFICATIONS, AND PERMITS
Provide one copy of: floor plan(s); site plan; sheets
Provide two site plans showing the location of all existing fire hydrants within 200 feet of the project.
3.,, Provide specifications for the following:
Permits are required for the installation of all fire protection systems (s prinklers,stand pipes, dry chemical, halon,
CO2, alarms, hydrants). Plan must be approved by the fire department Ffort1nstaIIation.
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:
VAtomatic fire sprinklers (Design Criteria: AS Pt .4 1,i- /— -
Dry Chemical, Halon, CO2 (Location:
Stand Pipes (Type:
0 Fire Alarm (Type/Location:
_J 7. Fi.Etinguisher Requirements:
l!1 One 2A rated ABC extinguisher for each, (O 01' ' sq. ft. or portion thereof with a travel distance to the nearest
extinguisher not to exceed 75 feet of travel.
An extinguisher with a minimum rating of _________ to be located:
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.
A sign stating, This door to remain unlocked during business hours" shall be placed above the main exitand
dooTh
11. EXIT signs (6" x 3/4" letters) shall be placed over all required exis and directional èigns located as necessary to
clearly indicate the location of exit doors.
GENERAL
....i12. Storage, dispensing or use of any flammable or combustible liquids, flammable liquids, flammable gases and
hazardous chemicals shall comply with Uniform Fire Code.
Building(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.
4. Additional Requirements.
Y(OL)10E,
(t q k)t
15. Comply with regulations on attached sheet(s).
Plan Examiner C - Date
Report mailed to architect _______ Met with Attach to Plans
COMMERCIAL/INDUSTRIAL
APPLICATION FORM FOR INDUSTRIAL WASTE DISCHARGE PERMIT
CITY OF CARLSBAD
APPLICATION: NEW______________
(CHECK ONE) REVISED__________
BY:
Signature of City Representative .
BUILDING P.C. NO.:___________
APPLICATION NO.: j
INDUSTRIAL CLASS: 3
DATE:_____________________
APPLICATION FOR INDUSTRIAL WASTE DISCHARGE PERMIT
GENERAL:
SITE
- ,TCANT: ii/(eiJ ADDRESS ,4 /Z)
o ,T4PE OF BUSINESS:________________________________________
rJ
* ,MSPLICANTJS ADDRESS..O29() /) Mco
WASTES AND PROCESSING: (Check where applicable)
ci EP Domestic Waste Only i1 Industrial Waste Industrial Waste NOT
Discharged to Sewer Discharged to Sewer
0- GENERAL DESCRIPTION OF WASTE (Chemical and Physical Characteristics of
proposed waste):________________________________________________________
GENERAL DESCRIPTION OF PROCESS (If Applicable):__________________________
WASTES TO BE DISCHARGED TO SEWER:
WASTE: TREATED: QUANTITY: AVERAGE GPD
(Check One) UNTREATEDX (Daily) MAXIMUM GPD
(Gallons Per Day)
APPLICANT OR REPRESENTATIVE OF FIRM:2ff Allev
(Print)
DATE: //1 r/ ZTURE: Nø4/ ______