Statement of Intended Use

Please complete this form and you will be taken to the second part of the form to make payment. Various processes and situations in commercial and industrial establishments can create fire and life safety hazards. In order to provide a reasonable degree of safety to life and property, specific requirements have been established in the Fire, Building, and Life Safety Codes. To help us determine what particular laws apply to your business, please provide the following information. If you answer “YES” to any of the questions in Part II, III, or IV your business may require a permit. At the time of inspection, if it is deemed your business is a “permitted occupancy,” the inspector will notify you, and an invoice will be mailed out to be paid within 30 days.

Certificate of Occupancy Application Pay with Invoice

Step 1 of 3

33%

FIRE INSPECTION FEES CAN BE VIEWED IN THE AVFPD FEE ORDINANCE Please note: This application must be completed for all non-residential users, including business relocation and/or change of ownership. Completion of this application IS NOT an authorization to alter or occupy the premises.

Business Name(Required)

Business Address(Required)

Street Address City ZIP / Postal Code

BUSINESS DESCRIPTION:(Required)

PRIOR Use:(Required)

BUSINESS OWNER:(Required)

PHONE:(Required)

Mailing Address(Required)

Street Address Address Line 2 City Zip Code

EMERGENCY CONTACT:(Required)

PHONE:(Required)

Emergency Phone

BUILDING OWNER:(Required)

PHONE:(Required)

Building Owners phone

Email(Required)

TOWN OF APPLE VALLEY PERMIT #(Required)

SQ FT OF LEASED SPACE:(Required)

Statement of Intended Use: Questionaire

Will you store or handle an aggregate quantity of aerosol products in excess of 500 lbs.?(Required)

Yes

Will you install or operate a stationary lead-acid battery system more than 100 gallons?(Required)

Yes

Will you produce dust or loose combustible fibers in excess of 100 cubic feet?(Required)

Yes

Will you be storing more than 2,500 cubic feet of combustible materials (boxes, rubber?)(Required)

Yes

Will you store, handle or use compressed gasses? (Table 105.5.9)(Required)

Yes

Will you produce, store or handle cryogens? (Table 105.5.11)(Required)

Yes

Will you engage in the business of dry cleaning?(Required)

Yes

Will you conduct an operation which produces combustible dusts (i.e. flour, magnesium)?(Required)

Yes

Will you have any explosives or blasting agents?(Required)

Yes

Will you store, handle, use or dispense flammable or combustible liquids?(Required)

Yes

Will you store, transport on site, dispense, use or handle hazardous materials? (Table 105.5.22)(Required)

Yes

Will you have over 500 square feet of high-piles combustible storage? >12 feet)(Required)

Yes

Will you store, handle or use liquefied petroleum gases? (LPG)(Required)

Yes

Will you melt, cast, heat treat or grind more than 10 lbs. of magnesium?(Required)

Yes

Will you have a motor vehicle fuel dispensing station?(Required)

Yes

Will you manufacture more than 1 gallon of organic coating per day?(Required)

Yes

Will you operate an industrial baking or drying oven?(Required)

Yes

Will you operate a place of assembly (Drinking, Dining, Gathering) for more than 49 people?(Required)

Yes

Will you store or handle radioactive materials?(Required)

Yes

Will you have a refrigeration system with >200 lbs. Group A1 or >30 lbs. of any other refrigerant?(Required)

Yes

Will you operate a repair garage for servicing or repairing automobiles?(Required)

Yes

Will you be conducting hot work? (Welding, cutting or use flame producing devices or torches)(Required)

Yes

Will you apply flammable or combustible liquids? (Spray booth, dip tank, powder coating, rolling)(Required)

Yes

Will you store over 1,000 cubic feet of tires in an outside area?(Required)

Yes

Will you store lumber, wood chips, hogged material or plywood in excess of 200 cubic feet?(Required)

Yes

Is your building equipped with automatic fire sprinklers? If YES then:(Required)

Yes

Calculated sprinkler system GPM/SqFt Design Area (i.e. 3/3000)

(Density and certification information can usually be found on labels on the main sprinkler system riser for each system)

Calculated sprinkler system GPM/SqFt Design Area (i.e. 3/3000)

(Density and certification information can usually be found on labels on the main sprinkler system riser for each system)

Pipe Schedule (non-calculated) sprinkler system, Date system installed

Early Suppression Fast-Response (ESFR) sprinkler system

Other type Sprinkler System – list type and location:

Date of last sprinkler system 5 year certification (Title 19/NFPA25):

Fire sprinkler alarm monitoring company:

Is your building equipped with automatic fire detection? (Smoke detector, heat detector, manual pull)(Required)

Yes

Intended Use Statement

CHANGE OF OWNER ONLY:(Required)

Yes

MAKING TENNANT IMPROVEMENTS:(Required)

Yes

Number of Employees

Hours of Operation

Submit letter:(Required)

Drop files here or

Accepted file types: jpg, jpeg, pdf, Max. file size: 25 MB.

Submit a signed, legible letter (preferable type written and on your company's letterhead) stating your intended use for the property. In the letter, describe materials you will be storing and using on the property. Explain the method of storage (e.g. racks, pallets), storage dimensions, and where the materials will be located on the property. Describe how you will be using the materials. Explain any alterations to the building that are planned.

Light Hazard occupancy (office, classrooms, medical offices, etc.). Provide a minimum of (1) 2A10BC rated fire extinguisher mounted in an accessible conspicuous area. One extinguisher is required for every 6,000 square feet and the travel distance to a fire extinguisher shall not exceed 75 feet from any point.

Ordinary Hazard occupancy (mercantile storage, dining areas, display, warehouses and light manufacturing). Provide a minimum of (1) 2A20BC rated fire extinguisher mounted in an accessible conspicuous area. One extinguisher is required for every 3,000 square feet and the travel distance to a fire extinguisher shall not exceed 75 feet from any point.

Extra Hazard Occupancy (Hazardous Materials, flammable liquid, vehicle repair, cooking areas, woodworking, uses. Provide a minimum of (1) 2A40BC rated fire extinguisher mounted in an accessible conspicuous area. One extinguisher is required for every 2,000 square feet and the travel distance to a fire extinguisher shall not exceed 50 feet from any point.

Kitchen Hood System - Class K extinguisher required.

Note: These are typical minimum requirements. The Fire Marshal may require more fire extinguishers due to special operations or purposes being used. For example: spray booths, special electrical hazards, exotic metals and other situations will require increased protection.

Check that box that you understand and will apply these standards(Required)

I accept this information

THIS BUILDING WILL USE HAZARDOUS MATERIALS IN EXCESS OF NON-REPORTABLE AMOUNTS.(Required)

Yes

THIS BUILDING WILL NOT USE HAZARDOUS MATERIALS OR USES OF NON-REPORTABLE AMOUNTS.(Required)

Yes

NON-HANDLER DECLARATION

A hazardous material may be broadly defined as any material that because of its quantity, concentration, physical or chemical characteristics poses a significant, present or potential hazard to human health and safety, property or to the environment. A hazardous material includes, but is not limited to, a hazardous substance, hazardous waste and any material which a handler or the administering agency has a reasonable basis for believing would be injurious to the health and safety of persons or harmful to the environment if released into the workplace or the environment.

By signing below, I declare that the above named business/organization/occupant will not handle a hazardous material or mixture containing hazardous material which has the quantity at any one time during the reporting year equal to, or greater than a total weight of 500 pounds, or a total of 55 gallons, or 200 cubic feet at standard temperature and pressure for compressed gas.

High Piled Combustible Storage:

In Chapter 32 of the California Fire Code, high pile combustible storage is defined as: Storage of combustible materials (product and/or packaging) in closely packed piles (floor storage) or combustible materials on pallets, in racks or on shelves where the top of storage is greater than 12 feet in height. High piled combustible storage also includes certain high hazard commodities, such as rubber tires, group A plastics, flammable liquids, idle pallets and similar commodities where the top of the storage is greater than 6 feet in height.

It is very important to contact the Fire District prior to consideration of storing high-piled combustible storage. Many of the permit requirements must be built into your building. If your building is not approved for high-piled combustible storage it may be cost prohibitive. For example, if you have a pipe schedule sprinkler system - no high piled storage is permitted until the system is calculated. Securing a design professional is recommended to assist you with the code requirements.

THIS BUILDING WILL NOT BE USED FOR HIGH-PILED COMBUSTIBLE STORAGE(Required)

Yes

THIS BUILDING WILL BE USED FOR HIGH-PILED COMBUSTIBLE STORAGE.(Required)

Yes

Permit is Required. Contact the Fire District for permit requirements.

THIS BUILDING IS A SPECULATION BUILDING WITHOUT A TENANT AT THIS TIME.(Required)

Yes

The tenant will be notified to contact the Fire District prior to use of the building.

ALL APPLICANTS MUST SUPPLY THE FOLLOWING: Floor Plans(Required)

Accepted file types: jpgs, pdf, zip, Max. file size: 10 MB.

An inside floor plan that indicates where all windows, doors, equipment, furniture, etc., are located. If the business requires machinery, also indicate the locations.

More Files

Accepted file types: jpgs, pdf, zip, Max. file size: 10 MB.

More Files

Accepted file types: jpgs, pdf, zip, Max. file size: 10 MB.

More Files

Accepted file types: jpgs, pdf, zip, Max. file size: 10 MB.

Signature(Required)

Your Name
Your Name
Your Name

I certify that I have read this application, and the information provided is true and correct. I agree to comply with all State of California, Town of Apple Valley, San Bernardino County Laws and Apple Valley Fire Protection District Ordinances relating to this application and subsequent approval of permits or Certificates of Occupancy.

Date(Required)

Email Invoice to:(Required)

Please provide an email address where the invoice can be sent. Once received, payment can be made using the QR code or payment link included on the invoice. You may also call our office Monday through Thursday, from 8:00 a.m. to 5:00 p.m., to make a payment over the phone, or mail a check to: Apple Valley Fire Protection District 22400 Headquarters Drive Apple Valley, CA 92307

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Certificate of Occupancy Application Pay with Invoice

Statement of Intended Use: Questionaire

Intended Use Statement