PMT14-01948 {
i
I
City of Menifee Permit No.: PMT14-01948
�.�, 29714 HAUN RD.
' CC : MENIFEE, CA 92586 Type: Commercial Plumbing
EL-A
swmw A MENIFEE Date Issued: 07/28/2014
PERMIT
Site Address: 27774 NEWPORT RD, MENIFEE, CA Parcel Number: 336-380-008
92586 Construction Cost: $9,500.00 !,
Existing Use: Proposed Use:
Description of INSTALLATION OF GREASE INTERCEPTOR 1500 gal
Work:
Owner Contractor
NEWPORT TOWNE SQUARE, LLC. A GOOD PLUMBING INC
5051 AVENIDA ENCINAS 24335 PRIELIPP RD#119
CARLSBAD, CA 92008 WILDOMAR, CA 92595 -
Applicant Phone: 9516774400
A GOOD PLUMBING License Number: 934250
2714 STINGLE AVE
ROSEMEAD, CA 91770
Fee Description Qttv Amount f$1
Building Permit Issuance 1 27.00
�"a�itlonal OR .eUiewlulttbliig �'�E 'L �17�&�37�
GREEN FEE 1 1.00
$292.37
The issuance of this permit shall not prevent the building official from thereafter requiring the correction of errors in the plans and
specifications or from preventing builiding operations being carried on thereunder when in violation of the Building Code or of any other
ordinance of City of Menifee.Except as otherwise stated,a permit for construction under which no work is commenced within six
months after issuance,or where the work commenced is suspended or abandoned for six months,shall expire,and fees paid shall be
forfeited.
AA_Bldg_Permit_Template.rpt Page 1 of 1
City Of Menifee
LICENSED DECLARATION
I hereby affirm under penalty or perjury that I am licensed under provisions of ❑ I, as owner of the property an exclusively contracting with licensed
Chapter 9(commencing with section 7000)of Division 3 of the Business and contractors to construct the project(Section 7044, Business and Professions
Professions Code and my license is in full force and.effect. Code:The Contractor's License Law does not apply to an owner of a property
License Class_(3 License No. 5 72�0> who builds or improves thereon, and who contracts for the projects with a
Expires- (—( Signature _�� licensed contractor(s)pursuant to the Contractors State License Law).
WORKERS'COMPENSATION DECLARATION
❑ lam exempt from licensure under the Contractors'State License Law for the
❑ 1 hereby affirm under penalty of perjury one of the following declarations: following reason:
I have and will maintain a certificate of consent of self-insure for workers' By my signature below I acknowledge that, except for my personal residence in
compensation,issued by the Director of Industrial Relations as provided for by which I must have resided for at least one year prior to completion of
Section 3700 of the Labor Cade, for the performance of work for which this improvements covered by this permit, I cannot legally sell a structure that I have
permit is issued.
Policy# built as an owner-building if it has not been constructed in its entirety by licensed
contractors. I understand that a copy of the applicable law, Section 7044 of the
'X I have and will maintain workers' compensation insurance, as required by Business and Professions Code,is available upon request when this application is
section 3700 of the Labor Code, for the performance of the work for which this submitted or at the following Web site:http//www.leginfo.ca.gov/calawhtml.
permit is issued.My workers'compensation insurance carrier and policy number are:
Carrier �/l/-T/O/J�- f7/i—G /A✓�- C19 - Property caner or Authorize gent Date
Expires Policy# �82(_1`l/�7s
❑ By my Signature below, I certify to each of the following: I am the property
Name of Agent Phone# owner or authorized to act on the property owner's behalf. I have read this
(This section need not be completed if the permit is for application and the information I have provided is correct. I agree to comply
one-hundred dollars($100)or less) with all applicable city and county ordinances and state laws relating to building
construction.I authorize representatives of this city or county to enter the above-
El I certify that in the performance of the work for which this permit is issued,I identified property for the inspection purposes.
shall not employ any persons in any manner so as to become subject to the
workers'compensation laws of California, and agree that if I should become — ?Sr-0-
subject to the workers' compensation provisions of Section 3700 of the Labor l'Property Owner or Authorized Agent Date
Code, I shall forthwith comply with those provisions. //��2 �(�
_��>�_ City Business License# 7011✓ t
Date; ?'2� —( S Applicant;�/^^^—^ V
WARNING: FAILURE TO SECURE WORKERS' HAZARDOUS MATERIAL DECLARATION
COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS WILL THE APPLICANT OR FUTURE BUILDING
($100,000), IN ADDITION TO THE COST OF COMPENSATION, DYES OCCUPANT HANDLE A HAZARDOUS MATERIAL OR A
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE MIXTURE CONTAINING A HAZARDOUS MATERIAL
LABOR CODE, INTEREST,AND ATTORNEYS FEES _0.N6 EQUAL TO OR GREATER THAN THE AMOUNTS
CONSTRUCTION LENDING AGENCY SPECIFIED ON THE HAZARDOUS MATERIALS
I hereby affirm that under the penalty of perjury there is a construction lending INFORMATION GUIDE?
agency for the performance of the work which this permit is issued (Section WILL THE INTENDED USE OF THE BUILDING BY THE
3097 Civil Code) APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE
Lender's Name DYES A PERMIT FOR THE CONSTRUCTION OR MODIFICATION
Lender's Address -Ergo DISTRICT
THE SOUTH COAST AIR QUALITY MANAGEMENT
DISTRICT(SCAQMD) SEE PERMITTING CHECKLIST FOR
OWNER BUILDER DECLARATIONS GUIDE LINES
I hereby affirm under penalty of perjury that I am exempt from the Contractor's PRINT NAME:
License Law for the reason(s)indicated below by the checkmark(s)I have placed DYES WILL THE PROPOSED BUILDING OR MODIFIED FACILITY
next to the applicable item(s)(Section 7031.5. Business and Professions Code: BE WITHIN 1000 FEET OF THE OUTER BOUNDARY OF A
Any city or county that requires a permit to construct, alter, improve, demolish, ;;'NO SCHOOL?
or repair any structure, prior to its issuance, also requires the applicant for the
permit to file a signed statement that he or she is licensed pursuant to the
provisions of the Contractor's State License Law(Chapter 9 (commencing with I HAVE READ THE HAZARDOUS MATERIAL
Section 7000)of Division 3 of the Business and Professions Code)or that he or S INFORMATION GUIDE AND THE SCAQMD PERMITTING
she is exempt from licensure and the basis for the alleged exemption. Any CHECKLIST. I UNDERSTAND MY REQUIREMENTS
violation of Section 7031.5 by any Applicant for a permit subjects the applicant to ❑NO UNDER THE STATE OF CALIFORNIA HEALTH AND SAFETY
a civil penalty of not more than($500).) CODE SECTION
MATERIAL25505I�EP533,ORI AND 25534 CONCERNING
El I, as owner of the property, or my employees with wages as their sole
compensation,will do( )all of or( ) porting of the work, and the structure is PRQPERTY OWNER OR AUTHORIZED AGENT
not intended or offered for sale.(Section 7044,Business and Professions Code; /.�Iy,,,"�„
The Contractor's State License Law does not apply to an owner of a property X!
who, through employees' or personal effort, builds or improves the property,
provided that the improvements are not intended or offered for sale.If,however,
the building or improvement is sold within one year of completion,the Owner-
Builder will have the burden of proving that it was not built or improved for the
purpose of sale).
CITY OF MENIFEE PLCK No: p 't I '�/I
29714 Haun Road Date: Date:
ells
Menifee, CA 92586 aB 1
Phone: (951)672-6777 Amount A3110unt ,� -
Fax:(951)679-3843 Ck#: Ck#:
CCU
Building Combination Permit G
To Be Completed By Applicant
Legal Description: Planning Case: F: L: Rt: R:
r.d.uun,>oa
Property Address: Assessor's Parcel Number.
27774 Newport Rd,Menifee,CA APN's 336-380-008,009,010,011
Projectflenanl Name-Flame Broiler I I�mt#: Floor#:
Name: Newport Towne Square, LLC phone No.760-438-7500 Fax No.760-4383056
OwnerrAddress:
Property 5051 Avendia Encinas, Carlsbad, CA unit Number Zip code 92008
Own
Email Address: grant@grantgacom
Name: Flame Broiler (Farid Kanji) Phone No.714-308-0863 Fax No._
Applicant Address 7420 E. Columbus Dr., Anaheim, CA Unit Number ZIP Code 92087
Email Address:flame54@live.com
Name:A Good Plumbing Phone No. 951-677-4400 Fax No.951-677-4949
Contractor Address: 24335 Prielipp Rd. city Wildomar state Zip code 92595
Contractor's CIt ray qeQ o. Contractor's City State of California License No. Classification:C36 Plumbing
tessre
Number of Squares:
Square Footage 1253sf
Description of work: Grease Interceptor Installation cost of work:$ 9500
Applicant's Signature Date: 7/28114
GIAt�
To Be Completed By City Staff Only
Indicate As R-Received or NIA-Not Applicable
5 Completes sets of fully dimensioned,drawn to sale plans which include: 1 set of documents which include
❑ Tide Sheet ❑ Elevations ❑ Electrical Plan ❑ Geo Tech/Soils Report(on cd only)
❑ Plot I Site Plan ❑ Roof Plan ❑ Mechanical Plan ❑ Title 24 Energy(on 8'h x 11)
❑ Structural Calculations
❑ Foundation Plan ❑ Cross Section ❑ Plumbing Plan ❑ Single Line diagram for elec.services over 400 AMP
❑ Floor Plan ❑ SW ctural Framing Plan A Details ❑ Shoring Plan ❑ Sound Report-Residential
Class Code: Indicate New Construction Alteration' Addition' MaanslMelhods
Work Type: Repair Retrole Revision to Existing Permit' Required? YES NO
Proposed Building Use(s): Existing Building Use(s):
#Buildings: #Units, #Stories: Will the Building Have a Basement?
Y of N
Bldg.Code Occupancy Group Indicate Indicate if YES or NOfIndicate,all Geo-tech.Haz.Zone
At Project ConstructionSpdnklered y: Coastal Zone
Completion: Type(s): C 0f O Noise Zone
Re ulmd7 YES or NO
q Listed on Historic Resources Inventory
CITY PLANNING STAFF ONLY
APPROVALS: Costal Commiss Arch.Review Board I Landmark Comm. Planning Comm.Zoning Administrator
Fee Exempt: City Project I JElec.Vehicle Charger Landmark Seismic Retrofit I Speclai case:alag.
Otfdal Approval
Expedite Project(s): Child Care City Project Green Building I IL,ndmaklAnomable Housing
For Staff Use Only
ButidmglSalety Per n l Speclaasl City Planning I civil Engmeenng EPWM-Admen TransportnUon Momt. I Rent Control
THANK YOU FOR HELPING US CREATE A BETTER COMMUNITY
NBO-062
Rev.Ofi/2014
New Business Fees Due? An ❑No ®TBD
' - Assigned S.O.#if Fees Due: PPI#:
-i Date Received: p f 6 PSN#
�*. Reviewed 8 Completed By: SA: ID; ICI
Originating Developer S.O.#: Thomas Bros: Dwg#:
TENANT IMPROVEMENT—REQUEST FOR RELEASE FORM
Is a New Service Connection required for this project? CJ Yes El No
F'YES STOP HERE AND PLEASE CONTACT T-it N!E.PJ SUSIYESS DE`r=LOP.,'ENT DEPA.RVVENT FOR,APPPOPRii TE FOn:2'S
AGENCIES REQUESTING RELEASE:
AGENCY PROVIDING WATER:
TYPE OF REQUEST: -gzenant improvement on newly constructed building
❑Tenant improvement on previously occupied building
CONTACT INFORMATION
BUSINESS OWNN5 ,NAME DATE7 NAME OF INDIVIDUAL REQUESTING RELEASE
�a -)Y
MAILING AD E �
SS PHONE COMPANYNAME PHONE
72-(/0 E- ColvNit.s hY
CI Y ZIP CELL RELATIONTOPROJECT CELL
411e1 Y'O IMOT 71 -Z05-0) 61
E-MAILADURb4ib ADDRESS FA%
j- q►►1 E St j (1 t3 c Cta ae�
PROPERTY MANAGEMENT COMPANY,IF LEASING SPACE CITY ZIP
PROPERTY MANAGEMENT COMPANY PHONE NUMBER EWAILADDRESS
BUSINESS INFORMATION
COMMERCIAL CENTER NAME PM)TRACTIAPN
BUSINESS NAME
AWL
SERVICEADDRESS BUILDINOMAD NUMBER SUITE NUMBERS
7 :4 t� EL 0 IVA 101
TV I ZIP
C A,— 9ZErr&&
PROJECT LOCATION(PLEASE SPECIFY CROSS STREETS
IF BUI DINGIS NOT NEWLVC NSTRUCTED PLEASE PRO DE NAME OF PR VIOUS OCCUPANT IF KNOWN
REQUIRED FOR MULTI-FAMILY,COMMERCIAL,INDUSTRIAL,AND INSTITUTIONAL PROJECT$:
-if any of the following apply,the applicant will be required to complete and sign an EI*VD Waste Discharge Application(Onsite Plumbing plans will also
be required):Questions pertaining to wasle dlSrharge mquiramePtS should be dlrecled to ENIVIvD:s Source Control Dept.1951 i 928-3?7T EXT 6209
YES NO
Are there any sinks other than hand sinks or floor sinks?
Are Floor drains installed in any area other than the restroom?
Is any water discharged to the sewer or other than from the restrooms?
Are any solvents or hazardous materials used or stored at your facility?
Is a water softener installed at your facility or do you plan to install one? 1 4
TO BE COMPLETED WHEN BUSINESS SITE 13 RECEIVING WATER FROM EMWD:
YES N
Use of chemicals,such as for industrial use? in
Chemical-additive injection(for fire-fighting) 10
On-site pumping of fire or domestic water service(S)
On-site water storage
On-site well
Unapproved au rifiary water supply
Sites with marine facilities(such as lakes and water parks)
t
i
NED-062
Rev.06/2014
COMPLETE THE APPLICABLE SECTION BELOW BASED ON THE TYPE OF OCCUPANCY OR BUSINESS:
REST,..,A,ppURANT: ASeats ❑INBAR:_-_Seats ❑IN PATIO:
SEATING CAPACITY IN: v Seats
MAXIMUM OCCUPANCY:
TOTAL SQUARE FOOTAGE: sq.tt. ,,,(
NEW IMPROVEMENTS/CHANGES FROM PRIOR BUSINESS: ❑ YES r NO
IF YES PLEASE EXPLAIN:
TYPE OF RESTAURANT(E,G.,CASUAL,FAMILY DINING ETC-)- �c
MEALS SERVED: 0 BREAKFAST LUNCH VDINNER
CHECK APPLICABLE ITEMS
LS,fDINE IN S %OF MEALS SERVED C7I'CARRY OUT ':9 %OF MEALS SERVED
❑ PAPER WRAPPING PAPER NAPKINS ❑ PLASTIC UTENSILS QI,..DISPOSABLE PLATES %OF MEALS SERVED
LINEN TABLECLOTHS ❑ LINEN NAPKINS ❑ CHINA % MEALS SERVED
•
BUILDING NUMBER I PAD NUMBER SUITE NUMBER SQUARE FOOTAGE
BUILDING NUMBERlPAD MBER SUITENUMBER SQ JA REFOOTA
•• BUILDING/PAD SUITE NUMBER SQUARE FOOTAGE NUMBER OF NUMBER OF NUMBER OF
NUMBER MACHINES REGULAR WASHERS EFFICIENT WASHERS -
• ' • BUILDING!PAD SUITE NUMBER SQUARE FOOTAGE NUMBER OF NUMBER OF
NUMBER HAIR WASH BOWLS PEDICURE SPA BOWLS
RETAILICOMMERCIAIJINDUSTRIAL PROJECTS SPECIFY PROPOSED USE(EXAMPLE:WAREHOUSE,MANUFACTURING,
OPEN STORAGE,RETAIL SALES,ETC.)
BLDG NUMBER/PAD NUMBER 1 SUITE NUMBER I BLDG SQUARE FOOTAGE PROPOSED USE OF BUILDING
BLDG NUMBER/PAD NUMBER SUITE NUMBER BLDG SQUARE FOOTAGE PROPOSED USE OF BUILDING
BLDG NUMBER/PAD NUMBER SUITE NUMBER BLDG SQUARE FOOTAGE PROPOSED USE OF BUILDING
BLDG NUMBER!PAD NUMBER SUITE NUMBER BLDG SQUARE FOOTAGE PROPOSED USE OF BUILDING
OTHER(SPECIFY) BLDG NUMBER!PAD NUMBER SUITE NUMBER I SQUARE FOOTAGE PROPOSED USE
ADDITIONAL INFORMATION
SIG—NA I LIKEB DA
EASTERN MUNICIPAL WATER DISTRICT
TUMLE
PRINT NAME � P 227 OR BOX 6300 AD
PERRIS,CALIFORNIA 92572-8300
DEVELOPMENT SERVICES REPRESENTATIVE EXT. EMAIL PHONE:(951)928-3777
Traci Si wal# 9 g 4403 si waftt emwd.or FAX: v,EMVVD DRG
9 { L94 9 @ 9
2
MO-134(Rev"4/14)
Eastern Municipal Water District Site ID #
1 WASTE DISCHARGE APPLICATION
Date Due: _mil 11 / i Project#
Application #
Section A: (All applicants complete this Section)
A-1. Company Name:
Site Address. 21"1-74 1l=t_, �Z L Suite:
City, State: ;t C-- f /I Zip:
Site Tract No or APN (if known): Lot:
Site Telephone: ( ) Fax: ( )
A-2. Mailing Address: 0 '71{
City, State: [�/e. r i cA- Zip: IZs,1
A-3. Site Contact: ? A r i0 i<.f V 1 Phone: f714± su5 -c,) l�
Emergency Contact: Phone:
A-4. Workdays per week: (circle days)r M•.-T,(W._ - eTh . (F
No. hours of operation/day v i•s i No. of employees
A-5. List agency that provides water:
A-6. Provide a brief description of the commercial processes, manufacturing, or activities to be
performed at the site:
r
Provide appropriate SIC/NAICS codes:
A-7. YES NO (Check appropriate answer)
0' Q Are any sinks other than hand sinks or floor sinks (for condensate only) installed?
Cy 0 Are floor drains installed in any area other than restrooms?
Is any water discharged to the sewer other than from restrooms?
0 0 Are any solvents or hazardous materials used or stored at your facility?
OO Is a water softener installed at your facility or do you plan to install one?
EMWD USE ONLY
t]Tenant Improvement [ ] New Construction [ ] Change of Ownership [ ]Other
N.B. Initials TS First Release by Source Control Yes No Source Control Fees Yes No
New Business fees due - TS - 7/17/14 .
Section B (Ali applicants preparing or serving food complete Sections B)
B-1. Maximum Seating Capacity: `�, Maximum Meals Served @ Peak Hour: -
B-2. % Carry Out: % Single Service (i.e. disposable) Utensils:
B-3. a. No. Garbage Grinder b. Hot Grills: [ ] No [-YY/es
c. Dishwasher: ] No [ ] Yes d. Deep Fryers: [-Y'No [ ] Yes
e. No./Type of sinks, other than re/stroo 1m (e.g. floor, mop): ( t Ic9;
B-4. Oil/Grease Separator-Interceptor:[ ] No ( Yes
a. Size: j ri b. Location: 'u r{b 'f. ;� I I
B-5. Diagram: Provide a drawing that includes the location of all equipment that uses water(i.e. sinks,
dishwashers, garbage disposal, etc.) and the location of the water meter, grease interceptor,
water softener, and sewer connections. If available, attach detailed interior plumbing plans.
Section C (All applicants discharging wastewater (not from food service or restaurant) or
having on-site hazardous materials, please complete Sections C)
C-1. List all sources of wastewater, amount of discharge, and whether discharge is continuous or
intermittent:
Source Amount/Day Continuous-Intermittent
a. �� . C [ 1 111
b. 5�l•t � C [ 1 1 [ 1
C. �'. [� Cl 1 11 1
d. C [ 1 11 1
C-2. Chemicals used Amount/Dav/Wk/YrSaill Contained!
a. [ ] No [ ] Yes
b. [ ] No [ ] Yes
C. ( ] No [ ] Yes
C-3. Pretreatment-for sewered wastewater, list types (i.e. interceptor, clarifier, pH adjustment, silver
recovery) and location
Type Location
a. : L: r i: , �- t l ✓� C "r
r
b.
C.
C-4 List all hauled wastes
Type pp Transportation Co. How often
a.
b.
C.
C-5 EPA Generator Number:
'Spill Contained: If the chemical spilled accidentally, would the chemical flow into a
drain out of the building or would the chemical be "contained" so that cleanup could be
handled in a safe and legal manner.
{
Section C (continued)
i
C-6. Diagram: Provide a drawing (may be handwritten) including, but not limited to: a Basic floor
plan (include notation of areas which generate wastewater), the location of all water meters,
pretreatment equipment, hazardous chemical storage, hazardous waste storage, and sewer
connection (if known). If available, attach detailed interior plumbing plans.
Section D (All applicants complete this Section)
Certification Statement:
"I certify under penalty of law that this document and all attachments were prepared under
my direction or supervision in accordance with a system designed to assure that qualified
personnel properly gather and evaluate the information submitted. Based on my inquiry of
the person or persons who manage the system, or those persons directly responsible for
gathering the information, the information submitted is, to the best of my knowledge and
belief, true, accurate, and complete. I am aware that there are significant penalties for
submitting false information, including the possibility of fine and imprisonment for
knowing violations."
} lt11r_b I4, F31aJ X
Name of Authorized Representative Title
(Please 75t)
Signature of Authorized RepresentativeZ Date 7
/ f �-� � jti`.� - �:�i�K�
Email Address of Authorized Representative Phone No. for Authorized Rep.
Please return the white copies and keep the yellow copies for your records.
If you have any questions, call the Source Control Division at (951) 928-3777.
2As per Ordinance 59.6,Authorized Representative shall mean.
a. Responsible officer, if the User is a corporation or limited liability company,where that officer is
the manager of one or more manufacturing, production,or operating facilities,provided,the
manager is authorized to make management decisions which govern the operation of the
regulated facility including have the explicit or implicit duty of making major capital investment
recommendations,and initiate and direct other comprehensive measures to assure long-term
environmental compliance with environmental laws and regulations; can ensure that the
necessary systems are established or actions taken to gather complete and accurate
information for Control Mechanism requirements;and where authorityto sign documents has
been assigned or delegated to the manager in accordance with corporate procedures.
b. By a general partner or proprietor if the User is a partnership or sole proprietorship respectively.
c. If the User is a Federal, State,or local governmental entity or their agents,the principal executive
officer or director having responsibility for the overall operation of the discharging facility.
d. By a duly authorized representative of the individual designated in paragraph(a),(b),or(c)of this
definition if:
1.) The authorization is made in writing by the individual described in paragraph(a),(b),
or(c);
2.) The authorization specifies either an individual or a position having responsibility for
the overall operation of the facility from which the discharge originates,such as the
position of plant manager, operator of a well, or well field superintendent, or a
position of equivalent responsibility or having overall responsibility for environmental
matters for the company_
RIVERSIDE CTY/RIVERSIDE FAC. COUNTY OF RIVERSIDE • COMMUNITY HEALTH AGENCY
4065 COUNTY ICIRCLETAL DR-HEg104 )EPARTMENT OF ENVIRONMENTAL HEALTH
i for Review of Food Establishment Construction/Remodel Plans
07/17/2014 000001
47890 2:14PH DANNA0010 For Office Use
*COPY*
722020 $1233.DO Ck.# Trans.# Dist.# Area# SR#
#1200
#27774 epted unless this application is complete,and the plan check fee is paid.
CHEER $1233. 00
Job Address: - City: Zip:
Contact Person: Phone: L�
E-mail Address: Fax:
Contact's Address: City: Zip:
Owner/Operator Name: Phone:L�
Address: City: Zip:
A. General Construction (Additional operations may be subject to extra fees)
New Food Facility Remodel or Existing Food Establishment_Explain Remodel:
Total Sq.Ft.(including all seating areas) Hours of Operation
Seating Capacity for dining _ Number of workers per Shift
B. Service(Indicate ALL methods offood service to the public):
Menu:A menu of food and beverages sold at this facility is required to be submitted at time of plan submittal
On-site preparation(cooking,cutting,assembly,etc.):Yes No Soup or salad bar:Yes No ,
Customer Self-Service Dispensers:Yes No Full Service Bar:Yes No t
Type of customer utensils(cups,plates, forks,etc.)Multi-service(re-usable) or Single Services(disposable)
C. Utilities(Will-Serve Letters):
Water Service: Public Water System Name of Water Company:
Private Well(must be Environmental Health Land Use approved).
Sewer Disposal: Public Sewer System Name of Sewer Company:
Septic System(must be Environmental Health Land Use approved).
Grease Interceptor:Provide from Sewer District a Grease Interceptor size requirement letter or waiver letter.
Owner/Representative Declaration:I certify that I have read the entire application and state that all information is correct.I understand that the
amount of fee paid is based on my declaration of information on this form,and that incorrect information is grounds for denial of the submitted plans.
i also understand that plans will be discarded if not picked up within sixty(60)days of approval or denial,and that no inspection of my establishment
will be conducted,or approval granted to operate,until all proper information requested has been received and plans have been approved and
returned t have reviewed the Plan Construction Guide and my plans follow the guide.
Signature Date
l
DER-SAN-002(Rev.2/08) Distribution:White—Office.Yellow-Customer