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San Mateo Plan Check Application

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San Mateo Plan Check Application Powered By Docstoc
					                             San Mateo County Health Department                                     Establishment Type (check all that apply)
                             Environmental Health Services Division                                     Bar/Restaurant           Pool/Spa
                             2000 Alameda de las Pulgas, Suite 100
                                                                                                        Bed/Breakfast            Retail Food
                             San Mateo, CA 94403 www.smhealth.org/environ
                             (650) 372-6200   fax (650) 627-8244                                        Hotel/Motel              Other Food



                    Plan Check Application                                  Revisions or resubmittals do not require an application


FACILITY INFORMATION:                                                           NEW                                 REMODEL
Name of Facility:                                                       Phone Number:

Facility Address:                                                       City/ST/Zip


OWNER #1        INFORMATION:                                                      INFORMATION any):
                                                                       OWNER #2 INFORMATION (if (if applicable):

Name:                                                                   Name:

Home Address:                                                           Home Address:

City/ST/Zip:                                                            City/ST/Zip:

Email Address:                                                          Email Address:

Phone #:                                 Alt. #                         Phone #:                                 Alt. #


CONTRACTOR/ARCHITECT INFORMATION:

Company:                                                                Contact Person:

Address:                                                                E-mail Address:

City.ST/Zip:                                                            Phone #:                                 Alt. #


RESPONSIBLE PARTY FOR PLAN CHECK FEES:

      OWNER #1                 OWNER #2               CONTRACTOR/ARCHITECT                other-please specify

         Plan Check Requirements: The department will retain one copy and two will be returned to the applicant. The applicant
         must then submit the approved plans to the local city building department.
               Plan Submittal Application                                  Environmental Health Application
               Three (3) sets of plans                                     One (1) set of specification sheets

Fees: Plan Check fees must be paid upon pickup of plans.
Environmental Health Plan Check Specialist will notify applicant when plans are ready for pickup.
I/We certify that the above information is true and correct. Upon signing this document, I/We acknowledge that I/we are
responsible for all plan check fees.

Print Name                                               Signature                                                        Date



Print Name                                               Signature                                                        Date


                             Please submit original application with your plans. Keep a copy for your records.
                                                                                                                             Type of Establishment
                                             San Mateo County Health Department
                                             Environmental Health Services Division                                       Bar/Restaurant         Pool/Spa
                                             2000 Alameda de las Pulgas, Suite 100
                                                                                                                          Bed/Breakfast          Retail Food
                                             San Mateo, CA 94403 www.smhealth.org/environ
                                             (650) 372-6200   fax (650) 627-8244                                          Hotel/Motel            Other Food


                                            Environmental Health Application
OWNER #1 INFORMATION:                                                          OWNER #2 INFORMATION /CONTACT (if applicable):

Name:                                                                          Name:

Home Address:                                                                  Home Address:

City/ST/Zip:                                                                   City/ST/Zip:

 Phone #:                                Alt. #                                Phone #:                                  Alt. #

Email Address                                                                  Email Address




FACILITY INFORMATION:                                                           SEND ANNUAL HEALTH PERMIT BILL TO:

Facility Name:                                                                                 Owner 1 address                        Owner 2 address
                                                                                                                                  *other-please specify below
Facility Address:                                                                          Facility Address

 City/ST/Zip                                                                          *

Phone Number:                                          seating capacity of facility                 square footage of retail establishment


             TOBACCO SALES PERMIT CONDITIONS: The permittee or your employee may not sell, give away, or in any way furnish any
             tobacco, cigarette, or cigarette papers or any other preparation of tobacco or instrument that is designed for the smoking or
             ingestion of tobacco or tobacco products to any person who is under the age of 18. The permit must be displayed in a
             prominent location where retail sales of tobacco are conducted.

 NOTIFY ENVIRONMENTAL HEALTH IN WRITING IF BUSINESS CLOSES OR CHANGE OF OWNERSHIP OCCURS
 HEALTH PERMITS ARE NON-TRANSFERRABLE. I/We certify that the above information is true and correct.

Print owner 1                                                     Signature                                                           Date


Print owner 2                                                      Signature                                                          Date

REASON FOR APPLICATION (check all that apply)

      New facility               Tobacco permit                 Stormwater                Change of ownership

      Change of facility name Previous Facility Name                                                     Date of Change

updated 10/17/2012
                                                       FOR OFFICIAL USE ONLY                                FYI ONLY: PLANS SUBMITTED
                                                                                                            01   Full                   05 Fruit NO Vegetables
      Permit fee amount                                                                                     02   Counter                06 No Fruit Yes Vegetables
                                                                                                            03   Specialty              07 No Fruit or Vegetables
Opening Date                                             Date Paid                                          04   Fruit & Vegetables     Inspection Codes
                                                                                                            RISK CATEGORIES
Record ID                                                PGM/ELE                                            1 low
                                                                                                            2 med
                                                                                                            3 high
REHS APPROVAL                                            DATE                                               4 susceptible population or food processing

				
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posted:11/5/2012
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