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HomeMy WebLinkAboutUST 5/201147 - - - - -- -- _ . III11�1111'��ll�llil _. •.. : : ; :. • ,E _ ,��: • -s,.. - . • „ - . - • - - � - - •_ , K - �. �':�::ALARM.S� � S i KL H04 R SYS EMS�.� �,- � °����. ���i��,:_.:�.�� . ' � . ASS �.�: �� � ���� U.ST: Permit No: Permit No. Permit.No: Permit -No. Permit No. Permit No. y7.3 .. address:: >cJ C�N 'Bakersfield, CA. 933. ':Date' a; • d' —;• - Rec I e 5- N si ness am e,: BUILDING.:S DARE .FEET., Q < 14$ PV LOG': r, ✓SYSTEM r`= -_ Nerti :Mod:, t t m 'Commercial Hood :Sys e - r Buiidin S Feet: 9 .q� e Date Time i - `k �F 'A s em r. -i�. /yam Q: t �-C • i n i31d S r alc 'ulat o V 4 p' 't=ire Sprinkler- ,System _ Y'�i _ . `iris:►- r e Tank' -t a` ve •rourod��S o _ Ur>der 'roundStora e:.Tank amino z� .' �'•S i'�na ture 9. .. • "Under round;Sto _ Tank 9 �modifica�on s y= .. .9. oval Undor round -Stora �e'; removal g; 9 Tank •,A� -,-; - - , - _ _ _ „ - - . _Si nat ure 9.. . _ .�� •F' - :,.. - ''s°j. •' .. Via... - Comments: I II�l1�I1111I111I�I 48 IE UNDERGROUND STORAGE TANKS APPLICATION TO PERFORM ELD / LINE TESTING / SB989 SECONDARY CONTAINMENT TESTING /TANK TIGHTNESS TEST AND TO PERFORM FUEL MONITORING CERTIFICATION PERMIT N0. ❑ ENHANCED LEAK DETECTION ❑ TANK TIGHTNESS TEST B. S`'F ,ARrN.,. T ❑ LINE TESTING ❑ SB -989 SECONDARY CONTAINMENT TESTING Q TO PERFORM FUEL MONITORING CERTIFICATION BAKERSFIELD FIRE DEPT. Prevention: Sere -ices 1501'Truxtun Ave. ", First Floor Bakersfield, CA 93301 Tel.: (661) 326 -3979 Fax: (661) 852 -2171 Page,1 of 1 . :,. . .: • .,:;. � �.,x... _"" �$LTE.INFORMATIO "N���:- 'a�.;;�' ,. ":,'.�`,�<r FACILI Y ' �, ro�n 3�Sga:o _ NA E & PHONE NUMBER/9F C T CT PERSON a er CT PERSON - b 3 ADDR SOS ' I Ins`OY 1 &40; 7 )9- q� ✓O� OWNERS NAME OPERAT S NNAP4E� evi o PERMIT TO OPERATE NO. NUMBER OF TANKS TO BE TESTED IS PIPING GOING TO BE TESTED? ❑ YES ❑ NO TANK# VOLUME CONTENTS 1 ao a 1©�z ems -D t esel i .. ; ... ..............,,,.: �..:::: �:;..:: ;•TANKTE TING�C.OMPANY�-= i' >z:'. "':';� NAME OF TESTING COMPANY Tanknology, Inc. NAME & PHONE NUMBER OF Michelle Cle horn -Youn CONTACT PERSON 800-666-1130 - -9 MAILING ADDRESS 41785 Enterprise Circle S. Suite D Temecula, CA 92590 NAME & PHONE NUMBER OF j1 0.1'1 CERTIFICATION #: TESTER OR SPECIAL INSPECTOR: `aC _ O DATE U TIME TEST TO BE 1( I I CONDUCTED; a n � � r 1 ICC #:� 5� 7 5 - (11 TEST METHOD SIGNATUR F AP LICANT - DATE: �-7 APPROVED BY DATE HAZARDOUS MATERIALS STATEMENT —Yes—No Will the applicant or future occupant handle hazardous material or a mixture containing a hazardous material equal to or greater than the amounts specified on the list of extremely hazardous substances? See checklist for guidelines. _ Yes — No Will the proposed building or modified facility be within 1000 feet of the outer boundary of a school? —Yes—No Will the intended use of the building by the applicant or future building occupant require a permit for construction or modification from the Kern County Air Pollution Control District ( KCAPCD) or from the Bakersfield Fire Dept? See checklist for guidelines. —Yes—No I have read the Hazardous Material Guide and KCAPCD Permitting Checklist. I understand my requirements under the Calif. Health and Safety Code Sec. 6.95 and Calif. Govt. Sec. 65850 and the requirements of the City of Bakersfield Fire Dept. regarding hazardous materials. Owner or Authorized Agen hone No. Date DECLARATIONS: The declarations below are mandated by the State of California under Section 19825 of the Health and Safety Code. LICENSED CONTRACTORS DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of the Division 3 of the Business and Professions Code and my license is in full force'and effect. Lic. Class Lic. No. Exp. Date Contractors Signature Date OWNER - BUILDER DECLARATION I hereby affirm that under penalty of perjury that I am exempt from the Contractors License Law for the following 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 or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 commencing with Section 7000 of Division 3 or the Business and Professions Code) or that he or she is exempt there from 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)): 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 Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself through his or her 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 or she did not build or improve for the purpose of sale). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044 Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon and who contracts for such project with a contractor(s) licensed pursuant to the Contractor License Law). I am exempt under Sec. B. & P. C. for the reason Owner Signature I Date WORKERS COMPENSATION DECLARATION I hereby affirm that under penalty of perjury one of the following declarations: Carrier I have and will maintain a certificate of consent to self - insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Policy No. 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, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code. I shall forthwith comply with those provisions. Applicant: Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000) IN ADDITION TO COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST AND ATTORNEY'S FEES 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 Civ. C.) Lenders Name Lenders Address I certify that I have read this application and state that the information contained herein is correct. I agree to comply with all city ordinances and state laws relating to building construction and hereby authorize representatives of the city to enter the above mentioned - property for inspection purposes. Signature of Applicant or Agent I Date CONSTRUCTION PERMIT BAKERSFIELD FIRE DEPARTMENT PREVENTION SERVICES B E R S P I D 1501 TRUXTUN AVENUE, 1 ST FLR FIRE BAKERSFIELD, CA 93313 ARTM T Office Phone: (661) 326 -3979 Application Number . . . . . Property Address . . . . . . ATN (11 Digits): Application type description Subdivision Name . . . . . . Property Use . . . . . . . . Application valuation . . . . Owner JACK IN THE BOX INC 9330 BALBOA AV SAN DIEGO CA 92123 -1516 SAN DIEGO CA 92123 11- 10000166 10 UNION AVE 139 - 370- 06 -00 -7 FIRE DEPT 0 Date 5 /11 /11 Contractor ------------------ - - - - -- OWNER ---------------------------------------------------------------------------- Permit . . . . . . MANDATED LEAK DETECT TEST Additional desc . . Phone Access Code . 1096080 Permit Fee . . . . 96.00 Plan Check Fee 96.00 Issue Date . . . . 5 /11 /11 ., Valuation . . . . 0 Expiration Date . . 11/07/11 ---------------------------------------------------------------------------- Fee summary Charged Paid Credited Due ----- -- ---- - - - - -- ---- - - - --- ---- - - - - -- -- -- - - - - -- ---- - - - - -- Permit Fee Total 96.00 96.00 .00 .00 Plan Check Total 96.00 96.00 .00 .00 Grand Total 192.00 192.00 .00 .00 CALL FOR INSPECTION (661) 326 -3979 Please state the Permit Number, the Job address, and the Type of Inspection. Requests for inspections should be made at least 48 hours in advance. DECLARATIONS Permit is issued in accordance with all applicable Federal, . State and Local Ordinances. The permittee has properly signed and dated the reverse side of this form. This Permit expires after 180 days of inactivity. I have reviewed the above application, and find it to be correct/complete. Permittee: Date: BAKERSFIELD CITY FIRE DEPARTMENT -- INSPECTION RECORD Post this Card at the Job Site and DO NOT Remove for Duration of Work Inspection Request Phone No. (661) 326 -3979 UST NEW INSTALL JOB DESCRIPTION: -F- tvlC— DESCRIPTION DATE SIGNATURE BACKFILL PRIMARY PIPE SECONDARY PIPE SECONDARY CONTAINMENT SENSORS AUTHORIZATION FOR FUEL ELECTRICAL SEAK -OFF TANK TESTING UST REMOVAL DESCRIPTION DATE SIGNATURE EVR UPGRADE MISC. ACTIVITY REMARKS: AST NEW INSTALL DESCRIPTION DATE SIGNATURE MODIFICATIONS MINOR / MAJOR AST REMOVAL DESCRIPTION DATE SIGNATURE rPRIOR TO OPERATION OF ANY SYSTEM, ALL UST AND /OR AST SYSTEMS SHALL BE INSTALL, COMPLETE AND ACCEPTED BY THE BAKERSFIELD CITY FIRE DEPARTMENT. FIRE DEPARTMENT (FINAL) BUILDING ADDRESS: 16 t' JOB DESCRIPTION: -F- tvlC— OCCUPANCY TYPE: OWNER: PERMIT NO. �p CONTRACTOR: // q,�� 6C,r.9� m PHONE # 6— /,,j FD 1743