HomeMy WebLinkAboutapplicationforbodyartfacilityplanreviewAPPLICATION FOR BODY ART FACILITY PLAN REVIEW
The applicant must complete all sections prior to providing services to the public. Please refer to the Body Art
Facility Application Plan Review Checklist and Guidelines for specific requirements of the California Health
and Safety Code, Safe Body Art Act. ALL CONSTRUCTION MUST BE COMPLETED IN ACCORDANCE WITH THE APPROVED PLANS. ANY CHANGES MUST BE APPROVED BY THE LOCAL ENFORCEMENT
AGENCY (LEA) AND APPLICABLE PERMITS OBTAINED BEFORE COMMENCING WORK.
TYPE OF SERVICE: TYPE OF APPLICATION: □TATTOO □BODY PIERCING □PERMANENT COSMETICS □BRANDING □NEW □REMODEL
ONSITE TREATMENT? YES □NO □
FACILITY INFORMATION:
FACILITY NAME ___________________________________ _
FACILITY ADDRESS _____________ CITY ________ STATE ___ ZIP CODE. __ _
MAILING/BILLING ADDRESS ___________ CITY _______ STATE ___ ZIP CODE ___ _
CONTACT FOR PLANS: _____________ EMAIL ADDRESS: _____________ _
BUSINESS PHONE NUMBER ___________ HOME/CELL PHONE NUMBER. __________ _
FAX NUMBER _______________ _
FACILITY SQUARE FOOTAGE: ______ SQ. FT. NUMBER OF STATIONS OR PROCEDURE AREAS: ____ _
REQUIRED DOCUMENTS FOR PLAN SUBMITTAL: □Two (2) Sets of Plans (Minimum paper size of 11"x17", drawn to scale)
□Room Finish Schedule □Equipment Schedule
□Copy of Manufacturer's Specification for Sterilization Unit (facilities with on-site treatment)
□Body Art Facility Infection Prevention and Control Plan (IPCP)
□Plan Review Fee
NOTE: A permit may be required by the local building department if structural changes, plumbing, mechanical or electrical work is performed. Please contact the appropriate department for assistance. Check also with your local City/County Zoning authority for other
restrictions that may apply.
FOR OFFICIAL USE ONLY
FA# _______ PR# _____ _ _ PLANS APPROVED BY: ____________ _
AMOUNT PAID: _____ DATE PAID ___ _ DATE: _____ AR# _____ SR# _____ _
Ronald Browder, Director of Environmental Health
Phone: (510) 567-6790 Fax: (510) 337-9234
September 2018