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~ oPRN'n•. R -® APPLICATIOW— BUSINESS LICENSE <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> MAR 18 2014 / <br /> BUSINESS LICENSE NO. <br /> •riax`a"•• ENVIRONMENTAL HEALTH <br /> TO $E.COMPLETED BY THE APPLICANT PRIOR TO FILINGTHI= APPLICATION: <br /> Business Information <br /> Business Name: ' <br /> Business Address: A4 Cross St Fti' <br /> DBA Mailing Address: City: State: ZIP: S Z� <br /> Phone#: 2O — ;zvsy Assessor Parcel Number(s): 2 <br /> Email: <br /> Other Businesses at this Address: <br /> Previous Business at Address: <br /> Description of Business Operation:: ' t j! <br /> Type of Organization: esingle Owner ❑ Partnership ❑ Corporation ❑ other. <br /> Estimated Number of Full Time Employees: Estimated Number of Part Time or Seasonal Employees: <br /> Applicant Last Name: Applicant First Name: <br /> Applicant Mailing Address: (J til/ Q y H .. <br /> City State - ZIP IV,51 ppricanl Phone No: <br /> Water Supply: ❑Public ©'M-slle Well Sewage Disposal: Pu is ❑ Septic System <br /> Will there be any sale of firearms? (] Yes KNO <br /> NOTE: ANY CHANGE OF OCCUPANCY MAY REQUIRE BUILDING IMPROVEMENTS AND NECESSARY BUILDING PERMITS. <br /> 1, affirm,under penalty of perjury that all the above Information Is true and correct Date: <br /> I,the Owner/Agent agree,to defend,indemnify, and hold harmless the County and Its �' 1 <br /> agents,officers and employees from any claim, action or proceeding against the County <br /> arising from the Owne,1A ent's project. <br /> Applicant's Signature: <br /> STAFF USE ONLY <br /> G/P Designation: T Zoning: — Use Type: 11AC L 9,/-y .� '� G. � <br /> DEPARTMENT APPROVED DENIED DATE <br /> Development Services ✓ Planner Name: <br /> Building Inspection <br /> Environmental Health Div A 3 <br /> Fire Wardene, <br /> Public Works <br /> M.H.C.S.D. <br /> Llcense Approved For. <br /> (, 2 <br /> Remarks: / <br /> C <br /> Occ.Grp. <br /> Accepted as Complete: Date- <br /> F/AppliwtionsFonns&Handouts/PlanningApplications/Business License(Revised 11-14.11) <br /> Page 2 of 6 <br />