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APPLICATION -BUSINESS LICENSE <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> BUSINESS LICENSE NOS..- IVE <br /> FORS2 9 2w <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION-j-N c. <br /> Business Information <br /> Business Name: <br /> Business Address: "11�11:14117194( Cross St <br /> DBA Mailing Address: S S >< City: m GK;i -1 state: Cd' ZIPQ S <br /> Phone#: Assessor Parcel Number(s): <br /> Email: I <br /> Other Businesses at thi dress: <br /> Previous Business at Address: J <br /> Description of Business Operation:: <br /> Type of Organization: ❑ Single Owner ❑ Partnership f9 Corporation ❑ Other: <br /> Estimated Number of Full Time Employees: Estimated Number of Part Time or Seasonal Employees: <br /> Applicant Last Name: Applicant First Name: LipsR,20 <br /> Applicant Mailing Address: <br /> Chy t State ZI Applicant Phone No: - <br /> Water Supply: []Public IN On-site Well Sewage Disposal: ❑ Public Septic System <br /> Will there be any sale of firearms? ❑ Yes No <br /> NOTE: ANY CHANGE OF OCCUPANCY MAY REQUIRE BUILDING IMPROVEMENTS AND NECESSARY BUILDING PERMITS. <br /> I, affirm, under penalty of perjury that all the above information is true and correct Date: <br /> 1, the Owner/Agent agree,to defend, indemnify,and hold harmless the County and its <br /> agents, officers and employees from any claim,action or proceeding against the County <br /> arising from the Owner Agent's proj n.f� <br /> Applicant's Signatu .' <br /> STAFF USE ONLY <br /> G/P Designation: (- Zoning: - ( Use Type: � - �U� <br /> DEPARTMENT APPROVED DENIED DATE <br /> Development Services Planner Name: <br /> Building Inspection <br /> Environmental Health Div <br /> FireWarden -& <br /> Public Works <br /> M.H.C.S.D. <br /> License Approved For.ye 1 1 <br /> Remarks: <br /> Oce.Grp. <br /> Accepted as Complete: Date: <br /> c u,_..o.._,d..__..... n__........... ...-....,o.......,._..,.__...._.e...,._....,., �� .,., D—9-f 7 <br />