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Home My WebLink About5201 WHITE Lane _UST FMC 4.29.10MA, i No. Permit No. Permit No. Permit No. Permit No. Permit No. /D /GdOD &L3 File Number: Ij7-7-cK-- Date Received: Vag _ /C) SYSTEM: New Mod. ❑ ❑ Commercial Blood System ❑ ❑ Fire Alarm System Address: S= / 4JA:.7-p f*lie Bakersfield, CA 933 Business Name: G o o d, i A 00 � • BUILDING SQUARE FEET: I INSPECTION LOG Building Sq. Feet: _ Calculation Bldg. Sq. Ft: ❑ ❑ Fire Sprinkler System ❑ ❑ Spray Finish System ❑ ❑ Aboveground Storage Tank ❑ ❑ Underground Storage Tank minor modification Underground Storage Tank removal Underground Storage Tank ❑ we Other: ;;C-AsilL. Comments: - - I IIIIIII IIIIIIII X11 32 IE 1. 2. 3. 4. Date Time Signature 04/29/2010 08:39 9099206453 PF SERVICES PAGE 01/03 kF. 39RVICES INC. Phone: (909) 9499141 25 N. 12' Avenue Fax: (909) 920 -US3 )gland, CA 91786 email: pfservices(Mverizon.not FACSIMILE COVER SHEET TO: Bakersfield Fire Department ATT: Prevention Services Fax Number: 661- 852 -2171 Dam: April 29, 2010 - From., Joan Fuerte P.F. Servioes Inc. NO. of Pages (including covemheet): 3 MESSAGE: Please find attached the completed Application to schedule a monitoring certification on one underground storage tank at Good Samaritan Hospital. I need to know the amount of fees to pay for this. Last year, I believe we paid $192.00. My customer needs to know how much the fees will be in order to issue a Purchase Order to get this completed. I also attached a copy of our Business Tax Certificate -- it expires 6/30110. Thank yoU for your assistance. jjt .,'Ofiakerif. +*4 'WOMRAECEI F- P * Type., 1 Dat"e.. "tiara' :rf 10: :1133: kLD J 6 CHID jot al".'-findered: Tot allj;o nt, A Al CONSTRUCTION PERMIT Application Number . . . . . Property Address . . . . . . ATN (11 Digits): Application type description Subdivision Name . . . . . . Property Use . . . . . . . . Application valuation . . . . Owner ------------------------ TRUXTUN PSYCHIATRIC MEDICAL GR 901 OLIVE DR BAKERSFIELD CA 93308 BAKERSFIELD FIRE DEPARTMENT PREVENTION SERVICES x s P D 1501 TRUXTUN AVENUE, 1sT FLR FIRE BAKERSFIELD, CA 93313 4R16_41& r ffice Phone: (661) 326 -3979 10- 10000133 Date 5/11/10 5201 WHITE LN 384 - 332- 04 -00 -1 FIRE DEPT 0 Contractor --------------- --- - - - - -- OWNER ---------------------------------------------------------------------------- Permit . . . . . . MANDATED LEAK DETECT TEST Additional desc . Phone Access Code 1000421 Permit Fee 96.00 Plan Check Fee 96.00 Issue Date . . . . 5/11/10 Valuation . . . . 0 Expiration Date . . 11/07/10 ---------------------------------------------------------------------------- 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 after180 days of inactivity. I have reviewed the above application, and find it to be correct/complete. Permittee: 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 • °• . f ~.. " ; '_- .� = +_ k : :. = h.' 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 ' _ • - s ?�� = z Date Signature ; _ -7 _ Vl P : r ; 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' compensatiodinsurance 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 Date 04/29/2010 08:39 9099206453 PF SERVICES CITY OF BAKERSFIELD 'OST CONSPICUOUSLY' wadO M r • • • ■ ■ Buguess name ..: P F SERVICES INC Loc=iou address .: OUTSIDE CITY 'Lie Nbr /Class ..: 10 00110612 CONTRACTORS Issue date ....: 5104 109 F,Viratian dace •.: 4130/10 PAGE 03/03 P F SERVICES INC Owner /Ofg= 125 N 12TH ST P P SERVICES INC UPLAND CA, 91786 FUERTE, PABB BUSINESS TAX CERTIFICATE IS HEREBY GRANTED. LICENSEE IS TO COMPLY WITH ALL LAWS-AND ORDINANCES. ISSUANCE OF THIS LICENSE DOES NOT CONSTITUTE AUTHORIZATION TO CONDUCT BUSINESS IF LICENSEE HAS NOT COMPLIED WITH ALLAPPLICABLE LAWSAND ORDINANCES. THIS LICENSE IS ISSUED NATHOUTW IFICATION THAT THE LICENSEE IS SUBJECT TO OR EXEMPT FROM LICENSING BY THE STATE OF CALIFORNIA. A- UNDERGROUND STORAGE TANKS APPLICATION TO PERFORM ELD /LINE TESTING/ SB989 SECONDARY CONTAINMENT. TESTING/TANK TIGHTNESS TEST AND FUEL MONITORING CERTIFICATION PERMIT # ❑ ENHANCED LEAK DETECTION ❑ TANK TIGHTNESS BAKERSFIELD FIRE DEPARTMENT Prevention Services H x s a 1600 Truxtun Ave., Suite 401 FIRE Bakersfield, CA 93301 ARfr Phone: 661- 326 -3979 e Fax: 661 - 852 -2171 Page 1 of 1 ❑ LINE TESTING ❑ SB-989 SECONDARY CONTAINMENT *X FUEL MONITORING CERTIFICATION .,••. •. ; ,., ., -. ..... '•�SITEINFORMATION,•�� FACILITY 0 S01M r A rl / 1;1 10J 1( C ME TLL�V,, el rl & PyON`EE # O�OI'l ICT P PERSON (Jv l � �� /rO� /Y�l ADDRESS Sa.o( W h ` 4n �! CI�E�S�IELA� CA 7,330 OWNER NAME � ,I tWa 0 vl / n �s I" f OPERATOR NAME 1 f t PERMIT TO OPERATE # # OF TANKS, TO BE TESTED: IS PIPING GOING TO BE TESTED? ❑ YES NO TANK # VOLUME CONTENTS 1 000 m / 1 & TANK'TESTING COMPANY,r, :�..,. -:::� '-. �':•. :. •_:'•. ':.� '•.., TESTING COMPANY ��• ,ski^ �C C.- ... NA E 8 PHONE F CONT PERSON r er� MAILING ADDRESS / n l /L/ r jj /) V�� IV� NAME & PHO �Frt5 TESTER O �E�/JA SPEC7OROC� / 7 �2� CQ[ �• , �l/ 3 � (^33 CERTIFICATION DATE d TIME TEST TO BE CONDUCTED ICC # C� / �% /J -T J (� [ b METHOU APPLICANT IG ATURE DATE - THIS APPLICATION BECOMES A PER IT W14 EN APPROVED AP ED BY a DATE FD209S (Rev 06/07) 010 -(Aaqv s r BAKERSFIELD CITY FIRE DEPARTMENT — INSPECTION RECORD Post this Card at the Job Site and DO NOT Remove fair of Work InsDection Reauest Phone No. (661) 326 -3979 BACKFILL PRIMARY PIPE SECONDARY PIPE SECONDARY CONTAINMENT AUTHORIZATION FOR FUEL ELECTRICAL SEAK -OFF DATE DATE PRIOR TO OPERATION OF ANY SYSTEM, ALL UST AND /OR AST SYSTEMS SHALL BE INSTALLED, COMPLETE AND ACCEPTED BY THE BAKERSFIELD CITY FIRE DEPARTMENT. FD 1743 04/29/2010 08:39 9099206453 UNDERGROUND STORAGE TANKS APPLICATION TO PERFORM ELD/LIN E TESTING/ SS989 SECONDARY CONTAINMENT TESTINGfrANK TIGHTNESS TEST AND FUEL MONITORING CERTIFICATION PERMIT 0 PF SERVICES PAGE 02/03 BAKERSFIELD FIRE DEPARTMENT Prevention Services RIVLB 1600 Truxtun Ave,, Sulte 401 WEI F Bakersfield, Qk 93301 *IAN Phone: 661 - 326-3979. fax, 661-852-2171 4ww Page I of I El ENHANCED LEAK DETECTION 13 LINE TESTING 13 SO-909 SECONDARY CONTAINMENT C3 TANK TIGHTN= U FUEL MONITORING CERTIFICATION FACTLSY( sk OW);TACT PeksoN rA rl I ff a Zm� Z40771ONEl L-114ve-7- (661)-39f,1f00,rA ADDReS5 -A K'5l;'-sf 9 e L T>, CA 7-3 30-- <,. � h I �e_ an l OWNER NAME &O'Dw Soma (I &ft 410&0 1' OPERATOR NAME PERMIT TO OPtRATE # OF TANKS To BE TESTED! 15 PIPING GOING TO BE TESTED? 13 YES NO TANK f VOLUME CONTENTS _. 000 0-1 TONnNG COMPANY F. vcenc-s fn c. NA 46 & PHO CONT t;kNEf[We I*EERSO. C"C Fit HAIUNG ADDRESS a /4 ve m (4 C- c2 /,I kt'd, C.,t 411 PY-4 CRICION * M 36533 Icc q 519 DATE A PERMIT W14Eff APPROVED. DATE NAME lk PhD F TE57ER DlfftAECI 11 6r m=170 j t DATE & nNE TEST TO 66 CONDUCTED APPUCANTfIGIATURE THIS APPLICATION BECOMES APPROVED BY Fb2095 (Rev 06/07) P.F. SERVICF-S tNG. City of Bakersfield -Fire Dept. Ix 4 GOC4 Sam Hosp 412912010 . 192.00 1-92.00