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,,TI*SATITA <br />A}trA <br />Pltttlv; <br />& Bt rL0tl(, <br />{ct\0 <br />Plannlng and Bulldlng Agency <br />Plannlng Dfulslon <br />20 Clvlc Center Plaza <br />P.O. Box 19E8 (M-20) <br />Santa Ana, CA92702 <br />(714) 647-s804 <br />www.santa-ana.org <br />CERTIFICATE OF OCCUPANCY <br />SUPPLEMENTAL <br />QUESTIONNAIRE <br />Please turn in thls completed form with your Certificate of Occupancy application. <br />Company Name (Print):Pacific Counseling Solutions <br />conract Name: Stacey E. Cohn <br />Address (business mailing address):1851 E. 1st Street, Suite 630 <br />City:Santa Ana State:CA 92705 <br />Phone No.323-428-1925 E-mailAddress:staceycohn. pcs@gmail.com <br />fl Cnange of Property Owner E Cnange of Occupant E Cnange of Use fl AOditional Occupant <br />1. The following best descrlbes my operatlon: <br />E Oflce Only E Retail Sales ! ltledical/Dental <br />E Warehouse/Manufacturing/Dlstrlbution f] RestauranUTake Out Food <br />n Otner (descrlbe) <br />2. Please provide a brief description of how the business operates at this site (for example, please <br />describe the general nature of the business, what activities occur on-site, the hours of operatlon, <br />open to the publlc)' Behavioral Therapy Services office - Mon - Fri 9AM-4PM, <br />closed to public, appoinment only (if needed). <br />3. What was the former type of business or use of facility? (Please contact the leasing agent or building <br />owner to determine pior business use./ <br />Legal offices <br />4. Has the building or space been vacant or is this a new building? Yes f] trto E <br />lf vacant, for how long? <br />5. Are you an independent contractor? Yes E ruo fl <br />6. Location of the business and suite number' 6th Floor - Suite 630 <br />tr lstfloor n 2dfloor [ _floor <br />7. Do you share the floor or business entrance with another business? Yes E No E <br />L What is the amount of square footage leased?120 <br />9. How much of the space, which you lease, is office? <br />E 1oo% tr soo/o tl so% <br />lf other than 100%, how is the remaining space used? <br />S:Planning\Clerical-Counter Forms\ <br />CofO Ouestionnai e O8-27 - 1 I <br />tr Less than 30%