HomeMy WebLinkAbout2628 GATEWAY RD; 125; CBC2021-0142; PermitBuilding Permit Finaled
(city of
Carlsbad
Commercial Permit
Print Date: 07/20/2021 Permit No: CBC2021-0142
Job Address: 2628 GATEWAY RD, # 125, CARLSBAD, CA 92009-1777 Status: Closed· Fina led
Permit Type: BLDG-Commercial Work Class: Tenant Improvement
Parcel#:
Valuation:
Occupancy Group:
#of Dwelling Units:
2132621900 Track#:
$72,162.80 Lot#:
B Project#:
Plan#:
Bedrooms: Construction Type:VA
Bathrooms: Orig. Plan Check#:
Occupant Load:
Code Edition:
Sprinkled:
Project Title:
12
2019
Yes
Plan Check#:
Description: OCEAN EYES OPTOMETRY: 1,115 SF T.I.
FEE
BUILDING PERMIT FEE ($2000+)
BUILDING PLAN CHECK FEE (BLDG)
Property Owner:
BRESSI RETAIL LLC
130 VANTIS DR, # 200
ALISO VIEJO, CA 92656
ELECTRICAL BLDG COMMERCIAL NEW/ADDITION/REMODEL
MANUAL BLDG PLAN CHECK FEE
MECHANICAL BLDG COMMERCIAL NEW/ADDITION/REMODEL
SB1473 GREEN BUILDING STATE STANDARDS FEE
STRONG MOTION-COMMERCIAL
Total Fees: $991.62 Total Payments To Date: $991.62
Applied:
Issued:
Finaled Close Out:
Inspector:
Final Inspection:
Contractor:
RNC CONSTRUCTION INC
41815 VARDON DR
04/21/2021
06/10/2021
TKers
07/20/2021
TEMECULA, CA 92591-3949-RIVERSIDE
(951) 422·1027
Balance Due:
AMOUNT
$507.89
$290.40
$60.00
$65.12
$45.00
$3.00
$20.21
$0.00
Please take NOTICE that approval of your project includes the "lmposition11 of fees, dedications, reservations, or other exactions hereafter
collectively referred to as 11fees/exaction.11 You have 90 days from the date this permit was issued to protest imposition of these
fees/exactions. If you protest them, you must follow the protest procedures set forth in Government Code Section 66020(a), and file the
protest and any other required information with the City Manager for processing in accordance with Carlsbad Municipal Code Section
3.32.030. Failure to timely follow that procedure will bar any subsequent legal action to attack, review, set aside, void, or annul their
imposition.
You are hereby FURTHER NOTIFIED that your right to protest the specified fees/exactions DOES NOT APPLY to water and sewer connection
fees and capacity changes, nor planning, zoning, grading or other similar application processing or service fees in connection with this
project. NOR DOES IT APPLY to any fees/exactions of which you have previously been given a NOTICE similar to this, or as to which the
statute of limitation has previously otherwise expired.
Building Division Page 1 of 1
1635 Faraday Avenue, Carlsbad CA 92008-7314 I 760-602-2700 I 760-602-8560 f I www.carlsbadca.gov
(_ City of
Carlsbad
COMMERCIAL
BUILDING PERMIT
APPLICATION
B-2
Plan Check (J,Y:;;c(-;). I r O ftf;J
Est. Value , ;15 f , £ S-6 · (.,)
PC Deposit _______ _
Date )-/ -;-:)./ -.-..1:i
Job Address 7,, <., l -c G Ct, \,-e. l).,(;Y:/ !Ld Suite: I l S-APN: "2 I 3 1. '-' ·z. I q o 0
Tenant Name; 0 Ct' a. V\ t ':j e .1 0 P h.> l'v\ ~ t-'I" <j lot #:
Year Built: ____ Occupancy:_____ Construction Type· VA Fire Sprinklers:~ t;;JA/C::W t;J
BRIEF DESCRIPTION OF WORK: 1 I
0 Addit_ion/New: __________ New SF and Use,. __________ New Sf and Use,
___ Deck SF, Patio Cover SF (not including flatwork)
~ Tenant Improvement: \ l I ~ SF, Existing Use \..1 t ("'/11;(•17 Proposed Use ✓r~ i / ,f?''"
_____ SF, Existing Use ______ Proposed Use _____ _
D Pool/Spa: ____ -'SF Additional Gas or Electrical Features? ___________ _
DD □□ □c:l D Solar. ___ KW,. ___ Modules,. ___ .Mounted, Tilt: Yes/ No, RMA: Yes/ No, Panel Upgrade: Yes/ No
0 Plumbing/Mechanical/Electrical Only: ------------------------
O Other:
This permit Is to be issued in the name of the Property Owner as Owner-Builder, licensed contractor or Authorized Agent of the
owner or contractor. The person fisted as the Applicant below will be the main point of contact throughout the permit process.
PROPERTY OWNER APPLICANT ·~ PROPERTY OWNERS AUTHORIZED AGENT APPLICANT 0
Name: Me \ 1 f ~ Q, w • 110::J Name: _________________ _
Address: G4-I 't) ~. V'lq Le. r W 9-"1 Address: _______________ _
City: ( q. v-l ~ 1.,,a 4 State; CA-Zip; q z. O ( / City: _________ State: __ Zip:. ___ _
Phone: 1 (,, 0 -~ l \--f" 4-z. I Phone: _________________ _
Email: Y'.Y':(,\1S(Cl-uJ1ll0j · od~91ma., 1. (J,.,,Email; ________________ _
DESIGN PROFESSIONAL APPLICANT O CONTRACTOR BUSINESS APPLICANT 0
Name: ________________ Name: ~,Jl t lt"\ ~OCJ,2.vf
Address: Address: 4 I <tJ I [ Va.. v d O 1ri Q ,,. , ve_
City:. _______ .State: Zip:____ City: :re WI~ C l, I Yr State: (' A Zip: t-1 2. ~-q I
Phone: Phone: q S" I -4 1-2 -I U l 1
Email: Email: V:: O"'\ <.... < ,:,, ,,... ; ~ ✓ v c-t-; o ~ iv,<.. e '/ vv-,, 1 I . t c V"\,,
Architect State License: State license: I O S oq '1 4 Bus. license: _____ _
1635 Faraday Ave carlsbad, CA 92008
B-2
Ph: 760-602-2719 Fax: 760-602-8558
Page 1 of2
Email: Building@carlsbadca.gov
Rev. 08/20
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Building Permit Inspection History Finaled
(city of
Carlsbad
--~ --PERMIT INSPECTION HISTORY for (CBC2021-0142) ,
Permit Type: BLDG-Commercial Application Date: 04/21/2021 Owner: BRESSI RETAIL LLC
Work Class: Tenant Improvement Issue Date: 06/10/2021 Subdivision:
Status: Closed -Finaled Expiration Date: 12/13/2021 Address: 2628 GATEWAY RD, # 125
IVR Number: 32918 CARLSBAD, CA 92009-1777
Scheduled Actual Inspection Type Inspection No. Inspection Primary Inspector Reinspection Inspection
Date Start Date Status
06/11/2021 06/11/2021 BLDG-84 Rough 159428-2021 Passed Tim Kersch Complete
Combo(14,24,34,44)
Checklist Item COMMENTS Passed
BLDG-Building Deficiency Yes
BLDG-14 Yes
Frame-Steel-Bolting-Welding
(Decks)
BLDG-24 Rough-Top out Yes
BLDG-34 Rough Electrical Yes
06/14/2021 06/14/2021 BLDG-17 Interior 159602-2021 Passed Tim Kersch Complete
Lath/Drywall
Checklist Item COMMENTS Passed
BLDG-Building Deficiency Yes
07/13/2021 07/13/2021 BLDG-Final Inspection 161725-2021 Partial Pass Tim Kersch Relnspectlon Incomplete
Checklist Item COMMENTS Passed
BLDG-Building Deficiency Pre final pending papeiwork Yes
BLDG-Plumbing Final Yes
BLDG-Mechanical Final Yes
BLDG-Structural Final Yes
BLDG-Electrical Final Yes
07/20/2021 07/20/2021 BLDG-Final Inspection 162309-2021 Passed Tim Kersch Complete
Checklist Item COMMENTS Passed
BLDG-Building Deficiency Pre final pending papeiwork Yes
BLDG-Plumbing Final Yes
BLDG-Mechanical Final Yes
BLDG-Structural Final Yes
BLDG-Electrical Final Yes
Tuesday, July 20, 2021 Page 1 of 1
DATE: 06/07/2021
JURISDICTION: CARLSBAD
PLAN CHECK#.: CB-CBC2021-0142
✓• EsG1I
A SAFEb,1ilt Compar1y
SET: II
PROJECT ADDRESS: 2628 Gateway Road #125
PROJECT NAME: TI Ocean Eyes Optometry
□ APPLICANT
□ JURIS.
~ The plans transmitted herewith have been corrected where necessary and substantially comply
with the jurisdiction's building codes.
0 The plans transmitted herewith will substantially comply with the jurisdiction's codes
when minor deficiencies identified below are resolved and checked by building department staff.
0 The plans transmitted herewith have significant deficiencies identified on the enclosed check list
and should be corrected and resubmitted for a complete recheck.
0 The check list transmitted herewith is for your information. The plans are being held at EsGil
until corrected plans are submitted for recheck.
0 The applicant's copy of the check list is enclosed for the jurisdiction to forward to the applicant
contact person.
0 The applicant's copy of the check list has been sent to:
Melissa Wiley
~ EsGil staff did not advise the applicant that the plan check has been completed.
0 EsGil staff did advise the applicant that the plan check has been completed.
Person contacted: Telephone#: 760-525-5421
Date contacted:
Mail Telephone
0 REMARKS:
By: Steven Miller
EsGil
(by: ) Email: melissawilley@gmail.com
Fax In Person
Enclosures:
05/13
9320 Chesapeake Drive, Suite 208 ♦ San Diego, California 92123 ♦ (858) 560-1468 ♦ Fax (858) 560-1576
DATE: 05/13/2021
JURISDICTION: CARLSBAD
PLAN CHECK#.: CB-CBC2021-0142
✓• EsG1I
A SAFEbuilt'Cornµany
SET: I
PROJECT ADDRESS: 2628 Gateway Road # 125
PROJECT NAME: TI Ocean Eyes Optometry
□ APPLICANT
□ JURIS.
D The plans transmitted herewith have been corrected where necessary and substantially comply
with the jurisdiction's codes.
D The plans transmitted herewith will substantially comply with the jurisdiction's codes
when minor deficiencies identified below are resolved and checked by building department staff.
D 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
until corrected plans are submitted for recheck.
D The applicant's copy of the check list is enclosed for the jurisdiction to forward to the applicant
contact person.
~ The applicant's copy of the check list has been sent to:
Melissa Wiley
D EsGil staff did not advise the applicant that the plan check has been completed.
~ EsGil staff did advise the applicant that the plan check has been completed.
Person contacted: Telephone#: 760-525-5421
Date contacted:
Mail Telephone
0 REMARKS:
By: Steven Miller
EsGil
(by: ) Email: melissawilley@gmail.com
Fax In Person
Enclosures:
05/13
9320 Chesapeake Drive, Suite 208 ♦ San Diego, California 92123 ♦ (858) 560-1468 ♦ Fax (858) 560-1576
Carlsbad CBC2021-0142
05/13/2021
PLAN REVIEW CORRECTION LIST
COMMERCIAL
PLAN CHECK#.: CB-CBC2021-0142
OCCUPANCY: B
TYPE OF CONSTRUCTION: VA
JURISDICTION: CARLSBAD
USE: Medical Office
ACTUAL AREA: TI 1115 Sq. Ft.
EXISTING BLDG 8000 sq. f.t
ALLOWABLE FLOOR AREA: 9000 No Change STORIES: 1 No Change
SPRINKLERS?: YES
REMARKS:
DATE PLANS RECEIVED BY
JURISDICTION: 04/21/2021
DATE INITIAL PLAN REVIEW
COMPLETED: 05/13/2021
FOREWORD (PLEASE READ):
HEIGHT: No Change .
OCCUPANT LOAD: 12
DATE PLANS RECEIVED BY
ESGIL CORPORATION: 04/26/2021
PLAN REVIEWER: Steven Miller
This plan review is limited to the technical requirements contained in the California version of
the International Building Code, Uniform Plumbing Code, Uniform Mechanical Code, National
Electrical Code and state laws regulating energy conservation, noise attenuation and access for
the disabled. This plan review is based on regulations enforced by the Building Department.
You may have other corrections based on laws and ordinances enforced by the Planning
Department, Engineering Department, Fire Department or other departments. Clearance from
those departments may be required prior to the issuance of a building permit.
Code sections cited are based on the 2019 CBC, which adopts the 2018 IBC.
The following items listed need clarification, modification or change. All items must be satisfied
before the plans will be in conformance with the cited codes and regulations. Per Sec. 105.4 of
the 2018 International Building Code, the approval of the plans does not permit the violation of
any state, county or city law.
To speed up the recheck process, please note on this list (or a copy) where each
correction item has been addressed. i.e., plan sheet number, specification section, etc.
Be sure to enclose the marked up list when you submit the revised plans.
----------····-···---···
., Carlsbad CBC2021-0142
05/13/2021
NOTICE: CITY AND ESGIL'S HOURS OF OPERATION ARE AFFECTED BY
THE CURRENT COVID-19 EPIDEMIC. PLAN REVIEWER MAY NOT BE
AVAILABLE TO ANSWER QUESTIONS BY PHONE, BUT MAY BE
REACHED BY E-MAIL AT stmiller@esqil.com . (858) 225-2775
GENERAL
1. Please make all corrections, as requested in the correction list. Submit FOUR new
complete sets of plans for commercial/industrial projects (THREE sets of plans for
residential projects). For expeditious processing, corrected sets can be submitted
in one of two ways:
1. Deliver all corrected sets of plans and calculations/reports directly to the City of
Carlsbad Building Department, 1635 Faraday Ave., Carlsbad, CA 92008, (760)
602-2700. The City will route the plans to EsGil and the Carlsbad Planning,
Engineering and Fire Departments.
2. Bring TWO corrected set of plans and calculations/reports to EsGil, 9320
Chesapeake Drive, Suite 208, San Diego, CA 92123, (858) 560-1468. Deliver all
remaining sets of plans and calculations/reports directly to the City of Carlsbad
Building Department for routing to their Planning, Engineering and Fire
Departments.
NOTE: Plans that are submitted directly to EsGil only will not be reviewed by the
City Planning, Engineering and Fire Departments until review by EsGil is complete.
2. Plans may be submitted in electronic format, subject to the jurisdiction's
approval. If so, they must have restrictions removed from the security settings.
Electronic plans with restrictions to markups, printing, or stamping will not be
approved.
3. A reminder that due to Covid-19, the City will not permit counter corrections.
Please make sure all the items are satisfied; otherwise, another round of
corrections will be necessary.
PLANS
4. Provide the names, addresses and telephone numbers of the owner and the
responsible design professionals on the Title Sheet. Sec. 107.2.
5. All sheets of the plans and the first sheet of the calculations are required to be
signed by the licensed architect, engineer, or the person responsible for the
plan's preparation. California State Law.
6. Please provide a signed copy of the Title 24 ADA Compliance sheet to page A 1
the Title page. Please see a copy of the Compliance Form at the end of the list.
7. City of Carlsbad requires that all plans provide completed Climate Action Plan
(CAP) Consistency Checklist, city form B-50. Even if you put N/A on everything
you still need to provide one.
Carlsbad CBC2021-0142
05/13/2021
8. On the cover sheet of the plans, specify any items that will have a deferred
submittal (trusses, fire sprinklers/alarms, etc.). Additionally, provide the
following note on the plans, per Sec. 107 .3.4.1: "Submittal documents for
deferred submittal items shall be submitted to the registered design professional
in responsible charge, who shall review them and forward them to the building
official with a notation indicating that the deferred submittal documents have
been reviewed and that they have been found to be in general conformance with
the design of the building. The deferred submittal items shall NOT be installed
until their design and submittal documents have been approved by the building
official."
MISCELLANEOUS LIFE/SAFETY
9. Page A-3 Please provide notes on the plans to show the suspended ceilings in
Seismic Design Categories D, E & F comply with ASCE 7-16 Section 13.5.6.2.2
as follows:
a. The width of the perimeter supporting closure angle or channel shall be
not less than 2.0 in. unless qualified perimeter supporting clips are used.
b. Closure angles or channels shall be screwed or otherwise positively
attached to wall studs or other supporting structures. Perimeter supporting clips
shall be qualified in accordance with approved test criteria per Section 13.2.5.
c. Perimeter supporting clips shall be attached to supporting closure angle or
channel with a minimum of two screws per clip and shall be installed around the
entire ceiling perimeter.
d. In each orthogonal horizontal direction, one end of the ceiling grid shall be
attached to the closure angle, channel, or perimeter supporting clip. The other
end of the ceiling gird in each horizontal direction shall have a minimum 0. 75-in
clearance from the wall and shall rest upon and be free to slide on a closure
angle, channel, or perimeter supporting clip.
e. Ceiling areas over 2500 ft.2 must have seismic separation joints or full
height partitions.
f. Ceilings without rigid bracing must have 2" oversize trim rings for
sprinklers and other ceiling penetrations.
FIRE EXTINGUISHING
10. Specify on the plans that portable fire extinguishers will be installed in the
building in accordance with Section 906.
ACCESSIBILITY
COUNTERS AND TABLES
11. Page A2 you need to note that the reception desk meets the following. The tops of
tables and counters shall be 34" maximum above the floor. Section 11 B-904.
Where a single counter contains more than one transaction station, such as a
bank counter with multiple teller window or a retail sales counter with multiple cash
register stations, at least one of each type of station shall be located at a section of
-----------------·.
. . . Carlsbad CBC2021-0142
05/13/2021
counter that is at least 36" long and no more than 28" to 34" high. Section 11 B-
904. The current detail is missing the 36" long.
ADDITIONAL
12. To speed up the review process, please note on this list (or a copy) where each
correction item has been addressed, i.e., plan sheet, note or detail number,
calculation page, etc.
13. Please indicate here if any changes have been made to the plans that are not a
result of corrections from this list. If there are other changes. please briefly
describe them and where they are located in the plans.
Have changes been made to the plans not resulting from this correction
list? Please indicate: D Yes D No
14. The jurisdiction has contracted with EsGil, located at 9320 Chesapeake Drive,
Suite 208, San Diego, California 92123; telephone number of 858/560-1468, to
perform the plan review for your project. If you have any questions regarding
these plan review items, please contact Steven Miller at Esgil. Thank you.
Carlsbad CBC2021-0142
05/13/2021
TITLE 24 ADA COMPLIANCE
Permit# -------------
THE ACCESSIBLE ROUTE(S} OF TRAVEL SHALL BE THE MOST PRACTICAL DIRECT ROUTE Ell:iWEEN
ACCESSIBLE POINTS.
I Ml THE DESIGNER/OWNER IN RESPONSIBLE CHARGE OF THIS f>~OJE:CT. I HAVE INSPEClED THE
PREMISES AND OETERMINED THAT TI-IE NEW RESTROOM(S) AND/OR AREA OF Al TERATION WILL
13E F"ULL Y ACCES$113LE ACCORDINO TO CURR&::NT CODE REQOIRl;;MENTS.
SIGNATURE _______________ _
Print Name, ________________ _
DATCc_ ______________ _
I AM THC DCSIGN[.R/QWNER IN RESPONSl□LE. CHA.Ri3E OF lHIS F-ROJECT, I HAVE IN5PEC1ED THE
SITE/PREMISES AND DETERMINED THA.T EXrSTING CONDITIONS SHALL BE MODIFIED IN f.ULL
COMPLIANCE \'YITH CURRENT SITE ACCESSIBILITY RE.QUIREMENiS TO THE EXTENT REQUIRED EIY
LAW
SIGNATURE ________________ _
P;i1t Nar10: _________________ _
DATE _______________ _
IF THE BUILDING INSPECTOR DETERMINES NON-COMPLIANCE WI tH ANY CURRE;NT ACCESSfBLITY
PROVISfON$ OF THE LAW, 1-£/SHE SHALL REQUIRE SUBMITTAL OF COMPLETE AND DCTAILED
PLANS TO BUl:..OING AND SAFETY DIVISION Or-THE DEVELOPMENT SERVICE~ l'Jf:PARMFNT FOR
FURTHER RE.VIEW. PLANS MUST CLl:;ARLY SHOW ALL EXISTING NON-COMPLYING CONDITIONS
AFFECTED BY THE REMODEL !INCLUDING SITE PLAN, FLOOR PLANS, DETAILS. ETC.} AND
PROl->OSE::.u MOUll-=ICA"I ION$ or [)~FICICNCll:S TO MEET CURRENTS f,,CCESSIBLITY PROVISIONS.
THE PLANS MUST BE SIGNED ANO DAT[□ BY TH[ flELO INSPECTOR PRIOR SUPMITTAL FOR PLAN
.REVIEW
IF THE BUILDING INSPECTOR DETERMINES THAT FULL COMPLJANC~ WITH CURRENT SITE
ACCESSIB1LITY REOIJIREMENTS IS NOT rROVl□E□ HEfSHE SHJ\LL R[QUIR[ SUDM!TTAL OF A
DETAILED SITE PLAN FORAODmONAL ~LAN RFVlFW ANO COMMFNTS.
"U:\ISIJildine: arid ~"rety\flANOOUTS \7Rlc .!4 ADA Ctlr'll!'li,HI(!!
--------------------
.Carlsbad CBC2021-0142
05/13/2021
[DO NOT PAY -THIS IS NOT AN INVOICE]
VALUATION AND PLAN CHECK FEE
JURISDICTION: CARLSBAD
PREPARED BY: Steven Miller
PLAN CHECK#.: CB-CBC2021-0142
DATE: 05/13/2021
BUILDING ADDRESS: 2628 Gateway Road #125
BUILDING OCCUPANCY: B
BUILDING AREA Valuation
PORTION ( Sq. Ft.) Multiplier
Tl B Occl.(ancy 1115 64.72
Air Corditioning
Fire Sprinders
TOTAL.VALUE
Jurisdiction Code CB By Ordinance
: 1997 UBC BI.Hldin g Permit fee ...
! 1997 UBC Plan Check Fee
I /'.J J;:
~ Complete Review
Reg. VALUE
Mod.
r Structural Only
rRepetithleFee
1 ..-1 Repeats
r other
1 Hourly
EsGil Fee
1--------1] Hr @ *
Comments:
($)
72,163
72,163
$326.94]
Sheet 1 of 1
□ □ □ □ □ □ □ □ □ □
ENCINA WASTEWATER AUTHORITY
INDUSTRIAL WASTEWATER DISCHARGE PERMIT
SCREENING SURVEY
6200 Avenida Encinas, Carlsbad, CA 92011
Phone: 760-438-3941 Fax: 760-476-9852
SourceControl@encinajpa.com
Date: 0 4-/ I <o /1. I
BusinessName: Oct~ Eyti opt-oVV'let:ry
Street Address: '2.-(., 2. lo (;, cd:c WCL\j f:-0, · S k · I 2 r
Email Address: "'"'-<-I i r S o-..w I I I~ • c cl @ q w-.a.1 I. r,1 V\-\
PLEASE CHECK HERE IF YOUR BUSINESS IS EXEMPT: (ON REVERSE SIDE CHECK TYPE OF BUSINESS) M
Check all below that are present at your facility: ~
Acid Cleaning
Assembly
Automotive Repair
Battery Manufacturing
Biofuel Manufacturing
Biotech Laboratory
Bulk Chemical Storage
Car Wash
Chemical Manufacturing
Chemical Purification
D Food Processing
D Glass Manufacturing
D Industrial Laundry
D Ink Manufacturing
D Laboratory D Machining/Milling D Membrane manufacturing
D (i.e. waterfilter membranes)
D Metal Casting/Forming D Metal Fabrication
D Metal Powders Forming
D Nutritional SupplemenWitamin D Manufacturing D Painting/Finishing
D Paint Manufacturing
D Personal Care Products
D Manufacturing
D Pesticide Manufacturing/ Packaging D Pharmaceutical Manufacturing D (including precursors)
D Dental Offices □Metal Finishing D Porcelain Enameling D Dental Schools D Dental Clinics D Dry Cleaning
□ Electrical Component
□ Manufacturing
□ Fertilizer Manufacturing
□ Film/ X-ra y Processing
D Electroplating
D Electroless Plating D Anodizing
D Coating (i.e. phosphating)
D Chemical Etching/Milling
D Printed Circuit Board D Manufacturing
D Power Generation D Print Shop
D Research and Development D Rubber Manufacturing
D Semiconductor Manufacturing D Soap/Detergent Manufacturing D Waste TreatmenUStorage
New Business? Ye~o□ SICCode(s) if known: ------Date operation began/will begin: 0 7 / Ir/ Z-I
Tenant Improvement? Yes~oO If yes. briefly describe improvement: 0 V Vi U. v e V.-. ON, I -
O (? to l'V'P ~ "'j c Ii"' , C.
Description of operations generating wastewater (discharged to sewer, hauled or evaporated): _________ _
Estimated volume of industrial wastewater to be discharged (gal/ day) : __ / __________________ _
Listhazardouswastesgenerated(type/volume): ___ / _________________________ _
Have you applied for a Wastewater Discharge Permit from the Encina Wastewater Authority? YesOoate: _____ .
Page 1 of 2
ENCINA WASTEWATER AUTHORITY
INDUSTRIAL WASTEWATER DISCHARGE PERMIT
SCREENING SURVEY
6200 Avenida Encinas, Carlsbad, CA 92011
Phone: 760-438-3941 Fax: 760-476-9852
SourceControl@encinajpa.com 1••'1twA>U<
""'""""' ----·-
The commercial enterprises listed below are a partial listing of businesses that are exempt from industrial wastewater discharge
permitting under normal operating conditions. They are exempt because (a) they discharge no process wastewater (i. e., they
only discharge sanitary wastewater with no pollutants exceeding any local limits ), and (b) they have no potential to negatively
impact the EWPCF or other wastewater treatment plants in the ESS. Any questions regarding exemptions should be referred
to EWA Source Control staff.
□ Automobile Detailer s
□ Barber/Beauty Shops
□ Business/Sales Offices
□ Cleaning Services
□ Carpet/Upholstery
□ Childcare Facilities
□ Churches
□ Community Centers
□ Consulting Services
□ Contractors
□ Counseling Services
□ Educational Services (no auto repair/film
□ Financial Institutions/Services
□ Fitness Centers
□ Gas Stations (no car wash/auto repair)
□ Grocery Stores (no film developing)
□ Residential based Businesses
developing)
D Hotels/ Motels (no laundry)
D Laundromats
D Libraries fil Medical Offices (no x-ray developing) 0 Mortuaries
D Museums
D Nail Salons
D Nursing Homes
D Office Buildings (no process flow) r.g. Optical Services CJ Pest Control Services (no pesticide repackaging for sale)
O Pet Boarding/Grooming Facilities
O Postal Services (no car wash/auto repair)
D Public Storage Facilities
O Restaurants/Bars
O Retail/Wholesale Stores (no autorepair/film
developing)
D Theaters (Movie/Live)
CERTIFICATION STATEMENT
I cert(/y that the in.formation above is true and correct to the best of my knowledge.
Signature:~ ------------Print Name: ~ \ i r l °'-w I I ~
yV1·1 cha..e..l LQA.uroV\
Date: o1-(t lo ('2.. I
Facility Contact: @c/ lb~"I f QEj:!tvS Tille: Qeve loeV'At,\/'\\.-D·,,,..ec luv-
ENCINA WASTEWATER AUTHORITY
6200AVENIDAENCINAS, CARLSBAD, CA Phone: 760-438-3941 Fax: 760-476-9852
S ... urccCc:,trc::a) c 1;,.:;inu.jp.:i .co; n
Page 2 of 2
OFFICE USE ONLY SAN DIEGO REGIONAL
HAZARDOUS MATERIALS
QUESTIONNAIRE
RECORD ID# _________________ I
PLAN CHECK # _________________ I
BP DATE
Business Contact
1-oVV't v.,e Ii r r
Telephone#
--, o-S'l.f-.f'fl/
Zip Code APN# q 'Z..00
Cit ca.vr ,k,a o( State Zip Code Plan File# cA 92..011
v
. Telephone#
i,,,.a.1 l.(OVV\ 1!oO -S-2..S'"-S''f-2. Applicant E-mail ""'(.hno...wi I ,o,f
The following questions represent the fa lily's activi 1es, NOT the specific project description.
PART I: FIRE DEPARTMENT -HAZARDOUS MATERIALS DIVISION: OCCUPANCY CLASSIFICATION: {not required for pro!ects within the City of San
Q!!e2}: Indicate by circling the item, whether your business will use, process, or store any of the following hazardous materials. If any of the items are circled,
applicant must contact the Fire Protection Agency with jurisdiction prior to plan submittal.
Occupancy Rating: Faclllty's Square Footage (including proposed project):
1. Explosive or Blasting Agents 5. Organic Peroxides 9. Water Reactives 13. Corrosives
2. Compressed Gases 6. Oxidizers 10. Cryogenics
3. Flammable/Combustible Liquids 7. Pyrophorics 11. Highly Toxic or Toxic Materials
4. Flammable Solids 8. Unstable Reactives 12. Radioactives
~ Other Health Hazards lJ None. of These.
questions Is yes, app Icant must contact t e aunty o an Iego atena s IvIsIon, venue, uIte
Call (858) 505-6700 prior to the issuance of a building permit.
FEES ARE REQUIRED Project Completion Date: Expected Date of Occupancy: 07 / I S' /2.. I
YES J (for new construction or remodeling p/ojects
1. Is your business listed on the reverse side of this form? (check all that apply).
2. Will your business dispose of Hazardous Substances or Medical Waste in any amount?
3. ~ Will your business store or handle Hazardous Substances in quantities greater than or equal to 55 gallons, 500
pounds and/or 200 cubic feet?
4. ~ I Will your business store or handle carcinogens/reproductive toxins in any quantity?
5. Will your business use an existing or install an underground storage tank?
6. Will your business store or handle Regulated Substances (CalARP)?
7. Will your business use or install a Hazardous Waste Tank System (Title 22, Article 10)?
8. Will your business store petroleum in tanks or containers at your facility with a total facility storage capacity equal to
or greater than 1,320 gallons? (California's Aboveground Petroleum Storage Act).
0 CalARP Exempt
I
Date Initials
□ CalARP Required
I
Date Initials
□ CalARP Complete
I
Date Initials
PART Ill: SAN DIEGO COUNTY AIR POLLUTION CONTROL DISTRICT (APCD): The following questions are intended to identify the majority of air pollution
issues at the planning stage. Your project may require additional measures not identified by these questions. Some residential projects may be exempt from APCD
requirements. If yes is answered for either questions 1, 2 or 5 or for more comprehensive requirements, please contact APCD at apcdcomp@sdcounty.ca.gov;
(858) 586-2650; or 10124 Old Grove Road, San Diego, CA 92131.
2. Will any load supporting structural members be removed?
YES i 1. ~ Will the project disturb 100 square feet or more of existing building materials?
3. (ANSWER ONLY IF QUESTION 1 or 2 IS YES) Has an asbestos survey been pelformed by an individual that has passed an EPA-approved
building inspector course?
4. □ □ (ANSWER ONLY IF QUESTION 1 or 2IS YES) Based on the survey results, will the project disturb any asbestos containing material? If yes, a
notification may be required at least 10 working days prior to commencing asbestos removal. Additionally, a notification may be required prior to
the removal of a load supporting structural member(s) regardless of the presence of asbestos.
5. □ ~ Will the project or associated construction equipment emit air contaminants? See the reverse side of this form for typical equipment requiring an
APCD permit. If yes, contact APCD prior to the issuance of a building permit.
6. □ □ (ANSWER ONLY IF QUESTION 5 IS YES) Will the project or associated construction equipment be located within 1,000 feet of a school
bounda ?
Briefly describe business activities: .
vv, I'"' 0 r; v-I C.e,
Briefly describe proposed project:
T-r-01ri:-ice.
I declare under penalty of pf:!rj\J that to the best of my knowledge and belief t e resl}Onses made hereiA are true and correct.
VVI e , ; rs a w 1 1 ~ 1/\C',, v::::::---,,,
Name of Owner or Authorized Agent Signature of Owner or Authorized Agent
o 4-I I '2. I
Date
FOR OFFICAL USE ONLY: FIRE DEPARTMENT OCCUPANCY CLASSIFICATION: _________________________________ _
BY-DATE· I I
EXEMPT OR NO FURTHER INFORMATION REQUIRED RELEASED FOR BUILDING PERMIT BUT NOT FOR OCCUPANCY RELEASED FOR OCCUPANCY
COUNlY-HMD* APCD COUNTY-HMO APCD COUNTY-HMO APCD
*A stamp in this box only exempts businesses from completing or updating a Hazardous Materials Business Plan. Other permIttIng requirements may still apply
HM-9171 (9/18) County of San Diego -DEH -Hazardous Materials Division