HomeMy WebLinkAbout17-2962 1879 Addison Ave E - Addition & Remodel Permit CITY OF
Project Type: Commercial Building Permit TWIN EALLs Applied Date: 10/30/2017
Permit Type: Commercial Addition Issued Date: 1 212 2/2 0 1 7
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Permit No.: 17-2962
Address: 1879 Addison Ave E
Owner Name: Sips Contractor: Craftmark Construction, Llc
1879 Addison Ave E 510 2Nd Ave S
Twin Falls ID 83301 Twin Falls ID 83301
208-251-3512 Phone: 208-404-2570
Contractor License/Registration# RCE-42892
Permit Information
Description of Work Addition&Remodel For New Coffee Shop
Property Location in City Limits Y
Lot Number 3&4
Block Number 1
Subdivision Name Glynn'S Addition
Number of Units 1.00
Sq.Ft.First Floor
Sq.Ft.Second Floor
Sq.Ft.Basement Finished
Sq.Ft.Basement Unfinished
Sq.Ft.Garage
Sq.Ft.Patio
Building Total Sq.Ft. 60.00
Project Value _ 38,000.00
Impact Fee Type Retail
Fee Date Description Qty/Hrs Fee City Amount Total
Waived
10/30/2017 Permit Fee Commercial City 38,000.00 No 469.00 469.00
10/30/2017 Plan Review Fee Comm.City No 304.85 304.85
10/30/2017 Impact Fee Fire Non-Residential 60.00 No 19.80 19.80
10/30/2017 Impact Fee Police Non-Residential _ 60.00 No 9.00 9.00
10/30/2017 Impact Fee Streets Retail 60.00 No 148.80 148.80
Total Fees: 951.45
Payment Amount: 951.45
Amount Due: 0.00
This permit is not transferable(between contractors)and becomes null and void if work is not commenced within 180 days or is
abandoned for a period of 180 days.
Property Owners: By signing this form you are certifying that you are the legal owner and will personally perform the work covered by
this permit. You recognize that this permit is only valid for the work on a primary or secondary residence and associated
outbuildings not used for commercial purposes. By signing this,you accept responsibilitly for all work being performed,and
understand that all work must be inspected by the City of Twin Falls, Building Department.
Any work in the right-or-way requires a seperate permit from the Engineering Department. Please contact them at 208-735-7248.
Inspection Line Phone Numbers:
BuiIding:208-735- 3 Electrical:208-735-7235 Mechanical:208-735-7289 Plumbing:208-735-7299
Signature: / Date: /�/,
CITY OF
Project Type: Commercial Building Permit `WIN FALLS
Applied Date: 10/30/2017
Permit Type: Commercial Addition
�oA�F SERVING Q�0
Building Permit Application
Address: 1879 Addison Ave E Permit No.: 17-2962
Owner Name: Sips Contractor: Craftmark Construction, Llc
1879 Addison Ave E 510 2Nd Ave S
Twin Falls ID 83301 Twin Falls ID 83301
208-251-3512 Phone: 208-404-2570
Contractor License/Registration# RCE-42892
Permit Information
Property Location in City Limits Y
Number of Units 1.00
Building Total Sq. Ft. 60.00
Project Value 38,000.00
Impact Fee Type Retail
Fee Date Description Qty/Hrs Fee City Amount Total
Waived
10/30/2017 Permit Fee Commercial City 38,000.00 No 469.00 469.00
10/30/2017 Plan Review Fee Comm. City No 304.85 304.85
10/30/2017 Impact Fee Fire Non-Residential 60.00 No 19.80 19.80
10/30/2017 Impact Fee Police Non-Residential 60.00 No 9.00 9.00
10/30/2017 Impact Fee Streets Retail 60.00 No 148.80 148.80
Total Fees: 951.45
Payment Amount: 0.00
Amount Due: 951.45
Building Permit Application Only - This is not an approved permit
This application is not transferable and becomes null and void if work is not commenced within 180 days.
Property Owners: By signing this form you are certifying that you are the legal owner and will personally perform the work covered by
this permit. You recognize that this permit is only valid for the work on a primary or secondary residence and associated
outbuildings not used for commercial purposes. By signing this, you accept responsibilitly for all work being performed, and
understand that all work must be inspected by the City of Twin Falls, Building Department.
Signature: Date:
T of WIN OF City of Twin Falls
IN
Building Department
324 Hansen Street East Phone: 208-735-7238
A F Quo
P.O. Box 1907 Fax: 208-736-2256
SFR�,N� Twin Falls, ID 83303-1907 www.tfid.org
Commercial Building Permit Application
Type of Permit Requested Date Received:
❑Commercial Site Plan-Buildable Lot Land Use:
❑New Complete Building ❑Multi-Family(3 or more units) Number of Units
El Shell Building-No Interior walls(no occupancy) DAddition Sq. Ft.
El Shell Building-with interior walls(no occupancy) ORemodel Total Cubic Feet **
❑Tenant Improvement in Shell Building ❑Other (**Fire District Only")
PROJECT INFORMATION
Project Address: 1879 Addison Ave E Twin Falls,ID 83301 Subdivision:
Business/Tenant using space: slPs Lot/Block:
Phone: 208.251.3512 Parcel#:
PROPERTY OWNER INFORMATION CONTRACTOR INFORMATION
Name: Brian Scott Business Name: Craftmark Constrution
Address: 2858 Sunray loop Address: 510 2nd ave S
City, State,Zip: Twin Falls ID 83301 City, State,Zip: Twin Falls, ID 83301
Phone: 208.251.3512 Phone: 208.404.2570
Fax: Fax:
Email: bescott22@gmai1.com Email: clint@craftmarkconstruction.com
State Registration#
&Expiration Date: RCE-42892
ARCHITECT INFORMATION ENGINEER INFORMATION
Business Name: Laughlin Ricks Architecture Business Name:
Contact Name: Colby Ricks Contact Name:
Address: 935 Shoshone St N Address:
City, State,Zip: Twin Falls, ID 83301 City, State,Zip:
Phone: 208.736.8050 Phone:
Fax: Fax:
Email: colby.lra@gmail.com Email:
ADDITIONAL CONTACTS: Proved Manager, etc
Business Name: Business Name:
Contact Name: Contact Name:
Address: Address:
City, State,Zip: City, State,Zip:
Phone: Phone:
Fax: Fax:
Email: Email:
1. Project Description:
Modernize the existing facility and provide a 60 sf addition
2. Project Value: $38,000
A. Project Value is used to calculate fees for the building permit. Project Value is the total value of the construction work
for which the permit is issued,including overhead and profit as well as finish work,painting,roofing,electrical,
plumbing,heating,air conditioning,elevators, fire extinguishing systems,other permanent equipment,and owner
supplied items. Project value excludes the value of the land.
I certify that the value&scope of work provided above are the most accurate available at this time:
R.ColbyRicks R.ColbyRicks D�pbanya,gaeabyR,-by amk, 10/27/2017
Dale:2D17.10.2716,24.03-06'00'
Print Name Signature Date
3. Planning&Zoning Information
A. Land Use Zone: c-1 E. Warranty Deed
B. Site Drainage Area with Calcs EXISTING F. Flood Plain
C. Landscaping Area EXISTING G. Water Tap Size
D. Parking Spaces 13 H. Sewer Tap Size
4. Building Information
A. Proposed Use Restaurant E.Tenant Improvement Area: 906 SF
B. Occupancy Groups: e OCCUPANCY F. Total Existing Building Area: 906 SF(323 easement)
C. Construction Type: VB G. Actual New Building Area: 1,289
D. Building Height: Existing H. Number of Stories: 1
5. Fire Information
***Attach a site-specific letter from the engineering department or other public water provider stating fire flow at hydrants.
Include static pressure if fire sprinklers are to be installed.***
A. Fire Flow:
B. Static Pressure:
C. Is there a fire alarm system? Llyes I( o Partial
D. Is the building fully fire sprinkled? No
If yes,will the sprinklers be used for:
Allowable Area Increase? =Yes Q[vo
Story Increase? =Yes[=]No
Fire-resistive Substitution? =Yes =Vo
If partially sprinklered,where?
E. Are there any classified areas? =1yes [ No(if yes,please show on plans and explain classification)
(This mostly has to do with electrical wiring)
***NOTICE***
All permits expire 180 days from the date of their issuance or the date of the last inspection. Expired permits will require
reactivation at such time that the responsible party decides to complete the project. Reactivation fees will be required on all
permits. Furthermore,any application that has not been issued or picked up after 180 days will become null and void.
***New commercial projects/and or additions with all the required submittals are not expected to exceed 4-6 weeks for the
initial review,but could take longer depending on needed revisions or current workload. Tenant improvements or remodels
are not expected to exceed 2-4 weeks,and Certificate of Occupancy only applications are not expected to exceed 1-2 weeks.
Please let the Building Department know if there are any unusual time constraints and we will work with you to move your
project forward as quickly as possible. Please keep in mind that any missing information from the below checklist will cause
delays in the processing of the permit application.
Commercial/Non-Residential/Multi-Family Plan Review Checklist
Notice to all applicants: This checklist is designed to provide the basic information needed to allow the various agencies
with the City to complete a plan review of the proposed project. The basic requirements outlined below may not be all
inclusive.
General Requirements for all NEW CONSTRUCTION plan submittals:
(THREE COMPLETE SETS OF CONSTRUCTION PLANS TO INCLUDE CIVIL PLANS CONTAINED WITHIN)
A minimum of (two) original wet-stamped sets are required.
CONSTRUCTION PLANS (NEW construction and Additions)
***(DESIGN PROFESSIONAL TO GO THROUGH LIST AND CHECK OFF THAT ALL REQUIREMENTS HAVE BEEN PROVIDED
ON PLANS.)
8 Code Analysis—Required information is detailed on the code Analysis form within the application.
❑ ComCheck Energy Analysis—Prepared by an Idaho licensed architect or engineer. (Required on remodel when changing
fixtures)(Include envelope, interior and exterior lighting compliance worksheets)
8 Architectural Site Plan(This is REQUIRED in addition to the civil site plan)To include:
❑ Scale to be a minimum of 1/8"per foot for large projects and%"per foot for smaller ones.
❑ Sheet sizes shall not be less than 24"x 36"and not more than 30"x 42".
❑ Location of new and existing structures with fully dimensioned measurements to property lines&other structures;
❑ Parking lot design—Including fully dimensioned space and aisle layout and detailed handicapped parking spaces.
❑ Accessible route of travel from parking spaces to the building entrance and connecting to the public right-of-way.
_ Foundation Plan—(stamped by the Design Professional performing the structural calculations)
Include all required structural steel reinforcing,tie downs and special inspection criteria.
W Floor Plan—Including all exit schemes,exterior wall openings,door swings,use designations,exit signage,location of fire extinguishers,
high pile storage areas. For tenant improvements or remodels, include floor plan of the entire building. Indicate the existing occupancies of
tenant spaces in contact with new tenant improvement or remodel.
8 Elevations—North,South, East,West(show building height dimensions)
8 Building Sections and Details—Including the room finishes for ceilings,walls and floors. Also, include schedules for all windows and
doors, indicating the type,size,safety glazing,and door hardware. UL Listings and details for fire separations. Provide fire stop material
specifications along with U.L.design details. Include sections of all walls showing height and how to be built.Also show any dropped down
ceilings or storage above ceilings and framing details.
❑ Structural Plans(stamped by the Design Professional performing the structural calculations)—Roof framing plan,floor framing plan,
header and beam schedules,strap locations,structural details,shear walls,shear wall schedule,lintels,lintel schedule and all other
structural information as indicated in the calculations or required by the Building Official.Any special details(i.e.,storage above restrooms)
Provide statement of special inspections per IBC 1704.1.1. A final report documenting required special inspections and correction of any
discrepancies noted in the inspections shall be submitted at a point in time agreed upon by the permit applicant and the building official prior
to the start of work.
❑ Conservation Elements—Insulation R-values,glazing U-Factors,glazing solar heat gain coefficient(SHGC)value, rough opening sizes.
❑ Electrical Plans—Exit signage,switching diagrams,lighting schedule with fixture, bulb and ballast type, number of bulbs per fixture,and
fixture wattage;exterior lighting bulb and ballast type,and type of control. Location of exit signage and emergency lighting shall coordinate
with the floor plan or the reflected ceiling plan.(list and give details of any classified areas)
❑ Mechanical Plans—Equipment schedule listing the make and model of the equipment and other information pertinent to compliance with
IECC;duct insulation R-values,mechanical system control schematic load calculations. Information regarding all fire rated penetrations,
smoke dampers,fire dampers,etc. Ventilation design&calculations. Mechanical engineering plans may be required on certain projects.
(Provide calculations on plans if using natural instead of mechanical ventilation)
❑ Plumbing Plans—Plumbing plan,isometrics,grease/sand interceptor details,and calculations to determine actual interceptor sizing
according to the requirements in the Uniform Plumbing Code. Be sure to include the sewer connection location,type and location of
reduced pressure backflow devices(s),gas line piping materials and calculations,water line piping layout and materials,and
drain/waste/vent piping layout and materials.
❑ MSDS Sheets:--(2)Two copies of the Material Safety Data Sheets and the location and quantities of storage of such materials shall be
provided with the building permit submittal where any chemicals or hazardous materials may be present.
❑ Structural Engineering Calculations—(2)two sets of Structural engineering calculations are required for all new construction,additions or
structural improvement/remodels/retrofits within existing buildings. Calculations must be stamped and signed by an Idaho Registered
Engineer or Architect. (Exception: parameters of section 2308 of the IBC 2012,and design will be required)
❑ Metal Building Drawings and Calculations_—Metal Building Drawings and structural engineering calculations will be required for all pre-
fabricated metal buildings,including concrete footing details. Calculations must be stamped and signed by an Idaho Registered Engineer or
Architect.
❑ Modular Buildings—Structural engineering calculations will be required for the foundation design for all modular buildings. Calculations
must be stamped and signed by an Idaho Registered Engineer or Architect. (Modular buildings are required to have Idaho Division of
Safety approval.)
8 Additional Handicap Accessibility Information—Define all handicapped access features for new construction per the current
International Building Code,ANSI A 117.1. For remodeling and tenant improvements,the area of improvement shall comply with the
access requirement for new construction. An accessible route of travel will be required to the remodeled/improved area.
❑ Fire Department Requirements—Location and type of fire extinguishers,fire alarms, hoods,sprinkler system,etc.
ElMechanical—HVAC Ventilation design IBC 1203.4(New as of 1-1-09)
❑ Provide statement of special inspections per IBC 1705.
❑ Completed Waste Water Survey(see http://www.tfid.org/departments/p-z/building/133-building-information)
CIVIL PLANS(NEW CONSTRUCTION)(Civil plans may be required for ADDITIONS)
• Civil Site Plan(Licensed Engineer or Architect required)—To include:
❑ Scale and format to be standard scale at between 1:10 to 1:60 scale;
❑ Sheet sizes shall not be less that 18"by 24".
❑ Legal description and/or record of survey for the property and a vicinity map and north arrow;
❑ Property lines and lot dimensions and building setbacks from property lines
❑ Right-of-way details including access,easements,utilities,drainage,wastewater, right of way to be dedicated;
❑ Right-of-way improvements,both existing and proposed;
❑ Fire department access(access must be 20 feet wide with a 70,000 pound load capacity and reach within 150 feet of any/or all ❑
portions of the exterior walls of the building(s);
❑ Fire hydrants within 1000 feet&fire line location must be shown on the site plan;a water model may be required to determine fire
flow.
❑ Any areas used for the storage or use of materials regulated by the IFC;
❑ Storm Drainage—On site retention structure design and calculations by a P.E.;
❑ Grading plan including finished floor elevations,accessible route and top of curb elevations.
❑ Utility services—Number of water services including size and location;sewer location and proposed connection to the main;
irrigation service size and location,grease interceptor(including a detailed design)for all food service occupancies;
❑ Landscaping—Including all types and locations of landscape areas with topography showing berms,tree,fencing, retaining walls,
waterways,trash enclosure/mechanical equipment areas with method of screening, loading docks,storage areas,pedestrian
ways,exterior lighting fixtures,irrigation methods and proposed building pad;storm water retention(City Code 10-11-2)
❑ Location of new and existing structures and distance between them.
❑ Parking lot layout, including fully dimensioned space&aisle layout,detailed handicapped parking spaces&accessible route
❑ Storm Drainage Calculations—To be stamped by an Idaho Registered Civil Engineer or Landscape Architect.
❑ Geotechnical report—when building within 100'of canyon rim.
❑ Water tap size needed(or well permit,if applicable)
❑ Sewer lateral location
❑ Proposed and existing curb,gutter,sidewalk,and driveway approaches.
❑ Flood Plain indicated if within 100 year or less flood zone.
HEALTH DISTRICT APPROVAL IS REQUIRED FOR ALL BUILDINGS WHERE FOOD IS BEING PREPARED. A LETTER
OF APPROVAL MUST BE SUBMITTED TO THE BUILDING DEPARTMENT PRIOR TO PERMIT ISSUANCE.
I(the designer in responsible charge) (Architect or Engineer) hereby certify that I have read and examined the above
application and checklist, and that all of the information provided and items checked are included as part of the initial permit
application submittal and are true to the best of my knowledge.
Digitally signed by R.Colby Ricks
R. Colby Ricks Da6te:2017.10.2716:32:56 1 0/27/1 7
Signature Date
***SAMPLE***
(may not be all inclusive)
City of Twin Falls
Plan Analysis Based on Latest Edition of IBC & IFC
Architect or Engineer of Record:
Job Address: City: St: Zip:
Legal Description:
Occupancy Classification: Occupant Load Per Area: 1: 2:
3: 4:
5: 6:
Number of Stories: Vestibule Req'd?: Yes: No: _ Total:
Floor Area: Basement: 1 st: Exits Required: Basement: 1 st:
2nd: 3rd: 4th: 2nd: 3rd: 4th: stories
Actually furthest travel distance to exit: (IBC Table 1016.1 &Table 1021.2)
Type of Construction: Allowable Area Calcs:
Area Increase:
Sprinkler System: Yes: No: Exit Signs: Yes: No:
Maximum Floor Area Allowed: Emergency Lights: Yes: No:
Special Inspections Required? Yes: No: Lighting Layout&ComCheck: Yes: No:
Firewalls Required? Yes: No: (If Yes, please provide cross section & UL Listing)
Occupancy Separation Required? Yes: No: (If Yes, please provide cross section & UL Listing)
Area Separation Required? Yes: No: (If Yes, please provide cross section & UL Listing)
Classified Areas? Yes: No: (If Yes, please show on plans and explain classification)
FIRE HYDRANTS WITHIN 1000 FT. Comments:
1. ft. GPM Flow:
2. ft. GPM Flow:
3. ft. GPM Flow:
Total:
Minimum Req'd Flow for Building:
Model Required?: Yes: No:
Date: Prepared By: * Fee may be accessed for water model'
CH2MHILL
400
CH2M HILL
P.O.Box 5158
Twin Falls,ID 83303-5158
Tel 208.734.9933
Fax 208.734.9937
Dear Wastewater Customer:
The City of Twin Falls is required by the Environmental Protection Agency(EPA)to conduct a Wastewater Survey of the users
within our service area. The reason for this survey is to determine if any wastewater discharged would be detrimental to the
wastewater collection and treatment system or the treatment process.
For purposes of notification, all industrial users (i.e., non-domestic users) are required to notify the Wastewater Treatment
Facility of hazardous wastes in accordance with 40 CFR 403.12 (p). (See back of letter)
We are asking that you please fill out the attached questionnaire as accurately and thoroughly as possible, and return it to us
in the envelope provided within the month. Please make sure the name of the company, address and a contact person is
included on the form.
In the next few weeks after the survey has been submitted, you may be contacted by telephone or in person by a
representative from CH2M HILL to answer any questions you may have and to gather any additional information we may
need for this survey.
If you have any questions, please contact Rebekka Bicart at 734-9933, or email "rbicart@ch2m.com".
Thank you for your cooperation.
Sincerely,
Rebekka Bicart
Industrial Pretreatment Coordinator
CH2M HILL
40 CFR 403.12 p)(1)The Industrial User shall notify the POTW,the EPA Regional Waste Management Division
Director, and State hazardous waste authorities in writing of any discharge into the POTW of a substance,which,
if otherwise disposed of, would be a hazardous waste under 40 CFR part 261. Such notification must include the
name of the hazardous waste as set forth in 40 CFR part 261, the EPA hazardous waste number, and the type of
discharge (continuous, batch, or other). If the Industrial User discharges more than 100 kilograms of such waste
per calendar month to the POTW, the notification shall also contain the following information to the extent such
information is known and readily available to the Industrial User: An identification of the hazardous constituents
contained in the wastes, an estimation of the mass and concentration of such constituents in the wastestream
discharged during that calendar month, and an estimation of the mass of constituents in the wastestream expected
to be discharged during the following twelve months. All notifications must take place within 180 days of the
effective date of this rule. Industrial users who commence discharging after the effective date of this rule shall
provide the notification no later than 180 days after the discharge of the listed or characteristic hazardous waste.
Any notification under this paragraph need be submitted only once for each hazardous waste discharged.
However, notifications of changed discharges must be submitted under 40 CFR 403.12 0). The notification
requirement in this section does not apply to pollutants already reported under the self-monitoring requirements
of 40 CFR 403.12 (b), (d), and(e). (2) Dischargers are exempt from the requirements of paragraph (p)(1) of this
section during a calendar month in which they discharge no more than fifteen kilograms of hazardous wastes,
unless the wastes are acute hazardous wastes as specified in 40 CFR 261.30(d) and 261.33(e). Discharge of more
than fifteen kilograms of non-acute hazardous wastes in a calendar month, or of any quantity of acute hazardous
wastes as specified in 40 CFR 261.30(d) and 261.33(e), requires a one-time notification. Subsequent months
during which the Industrial User discharges more than such quantities of any hazardous waste do not require
additional notification. (3) In the case of any new regulations under section 3001 of RCRA identifying additional
characteristics of hazardous waste or listing any additional substance as a hazardous waste, the Industrial User
must notify the POTW, the EPA Regional Waste Management Waste Division Director, and State hazardous
waste authorities of the discharge of such substance within 90 days of the effective date of such regulations. (4)
In the case of any notification made under paragraph(p) of this section,the Industrial User shall certify that it has
a program in place to reduce the volume and toxicity of hazardous wastes generated to the degree it has determined
to be economically practical.
For links to 40 CFR regulations go to www.gpoaccess.gov and click on Code of Federal Regulations.
Wastewater Survey
City of Twin Falls
1. Company Name:
Mailing Address
Telephone: Fax:
Email:
2. Facility Address:
If same as above Check
Telephone:
If same as above Check O
3. Contact Person: Title:
Telephone: Fax:
Email:
4. Type of Business Please Check all that apply to activities at your place of business.
❑ Retail-describe type(to the right),
❑ Small Office-describe type(to the right)
If you Checked either Retail or Small Office for your business type and none of the descriptions below apply to your business,please
answer Questions 5&6,and skip all other questions. Please be sure to sign and date this form Prior to returning
❑ Motels/Hotels/Clubs ❑ SchoolslCollegeslUniversities
Concern is efficiency of kitchen grease traps,frequency of clean out Concern is efficiency of kitchen grease traps,frequency of clean out,
disposal of grease. disposal of grease.
❑ Laboratory—Pharmacies ElLaboratory—Commercial &
Concern is hazardous materials,disposal of chemicals,and potential Schools/Colleges/Universities
for spills. Concern is hazardous materials,disposal of chemicals,and potential
for spills.
❑ Hospitals ❑ Dental Clinics
❑ Doctor's Clinics ❑ Photo Shops
Concern is with silver recovery.
❑ Restaurants
Concern is efficiency of kitchen grease traps,frequency of clean out, ❑ Barrel Reclaimers
disposal of grease
❑ Print& Photo Copy ❑ Arts & Crafts Shops
Concern is with paints&glazes(ceramic&other).
❑ Garages/Full Service Gas Stations ❑ Radiator Shops
Concern is flushing of antifreeze contaminated with metals.
❑ Paint& Body Shops ❑ Transportation Facilities
Concern is improper disposal of waste oils and inefficient grit traps.
❑ Industrial 1 Commercial Laundries ❑ Waste Haulers
❑Other—Describe principal activities or the nature of processes at the facility, in the space
provided below.
7. Standard Industrial Classification Code Number(s)and Classification(s)(if known):
8. Average total monthly water usage in gallons(monthly water billings will usually snow this).
9. Is the building presently hooked to the sewer system? 0 Y ON
10. Are there floor drains present at your facility? DY 0 N
11. Do you or will you use non-petroleum fats,oils or greases(cooking types of oil/grease)in y
business? Y ON
12. Do you or will you use petroleum oils or greases in your business? 0 Y ON
13. Grease trap present? DY ON
14. Describe any pretreatment facilities or practices used to remove pollutants or protect the sewer.
15. Do you or will you store or use chemicals on site in excess of household quantities? DY ON
16. Do you or will you discharge wastewater(other than domestic wastes from toilets,showers,etc.)to the Y N
sewer system? 0
17. Do you or will you have an Accidental Spill Prevention Plan(ASPP)for your business? DY ON
I certify that the information in this questionnaire is to the best of my knowledge true and complete. [This statement
must be signed by an official authorized to sign for the company.]
Signature: Date:
Print Name:
OFFICE USE ONLY
Additional information required?
Need to schedule site visit or other follow-up? 0 Y N
Need to send an Industrial User permit application? 0 Y 0 N
HAZARDOUS WASTE INFORMATION/NOTIFICATION(make copies&attach additional sheets if necessary)
Type of Discharge:
Name of Waste EPA Hazardous C—Continuous Describe Other
# Waste Number B—Batch,0-Other
1
2
3
4
5
6
7
8
9
10
If more than 100 Kilograms (220 pounds) of any hazardous waste per calendar month is discharged to the sewer, please
include the following items of information for each hazardous waste, to the extent such information is known and readily
available.
HAZARDOUS CONSTITUENT INFORMATION:
Concentration in
Name of Constituent Mass in Wastestream Wastestream Mass in Wastestream
(this month) (this month) (next 12 months)
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SEWER CAPACITY FEE WORKSHEET
Business Name: Address:
1. Please indicate the number of new and exisiting plumbing fixtures in the appropriate boxes below.
2. Also, the number of holidays being closed, the number of days the business is open in a week, and how many hours open
during the day.
3. If no plumbing fixtures are bing installed, signify at the bottom of the form and sign.
4. Sign and date.
VALUES Number VALUES Number
New DFU / Unit Existing DFU / Unit
Lavatories Lavatories
Water Closets Water Closets
Urinal Urinal
Water Softener Water Softener
Hand Sink Hand Sink
Dishwasher Dishwasher
Bar Sink Bar Sink
Clothes Washer Clothes Washer
Kitchen Sink Kitchen Sink
Shower Shower
Drinking Fountain Drinking Fountain
Mop/Svice-Sk/Tr Dr Mop/Svice Sk/Tr Dr
Hose Bibb Hose Bibb Holidays
Laundry Sink Laundry Sink Days/Wk
Floor Drain/Sinks Floor Drain/Sinks Hrs/ Day
Swimming pool Swimming pool
Hot tub/whirl pool Hot tub
Other Other
*No plumbing fixtures are being installed. Initial
Signature below indicates all information provided for on this form is accurate.
Name Date