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MAH 2 0 2018 <br />HEALTH <br />APPLICATION - BUSINESS LICENSE <br />SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br />BUSINESS LICENSE NO. t�C_ "4'•c7C)D (r, 1 <br />TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br />Business Information <br />Business Name: t Op L L_Qi&Tt2_�^zQToK. <br />Business Address: Cross St G <br />DBA Mailing Address: 9,6J6 eE- -Dr- City: ST State: CA ZIP: Q <br />Phone #: 0 4— Z Assessor Parcel Number(s); 3 a 090—Do <br />Email: Vern WHoLES�ALt- iyiA m <br />Other Businesses at this Address: NI�7'- <br />Previous Business at Address: 2 p.p ,.. , A (3 <br />Description of Business Operation.: 0 LU — > - O Gewmj I`y4rcvrwr,�� <br />To Ft a So lo N fTc . <br />Type of Organization: ❑ Single Owner ❑ Partnership I2"Corporation ❑ Other <br />Estimated Number of Full Time Employees: p Estimated Number of Part Time or Seasonal Employees: fl <br />Applicant Last Name: �w 6 h Applicant First Name: V <br />Applicant Mailing Add res s: • a6 lee (?e �r, <br />City <br />State C ZIPS <br />Applicant Phone Na. <br />Water Supply: ublic ❑ On-site Well <br />Sev(age Disposal. ❑ Public 177`Septic System <br />Will there be any sale of fireamis? ❑ 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 <br />I, the OwnerlAgent 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 project. <br />Applicant's Signature. µ"in <br />Date: 3 --T 118 <br />STAFF USE ONLY <br />GIP Designation: L Zoning: Use Type: ' i) )vz I, _-xa,• <br />DEPARTMENT APPROVED DENIED DATE <br />Development Services Planner Name: �3 �l�i �� <br />Building Inspection <br />Environmental Health Div <br />Fire Warden <br />Public Works <br />M. H.C.S.D. <br />License Approved For. Iv c_k CYQ <br />w�c wkA civ Z_ l_AeJ e - <br />Remarks: <br />h r '• _may —dU l SA -$ 8 22?s t31--0ff c 48 L o oo�a S� <br />Grp. <br />R),Ht,: <br />Accepted as Complete: <br />FlAppliwUon Fonns&Handouts/PlanningApplications/Business License (Revised 02-24-15) <br />Page 2 of 6 <br />