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APPLICATION - BUSINESS LICENSE <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FFS O ) Inn-16 BUSINESS LICENSE NO. ISL-rG �dB <br /> ::. EMJI-ONMENIN !-HEALTH <br /> ,1/JLi\'ll <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Business Information <br /> 1[Business Name: vl ,!.-� i✓� <br /> Business Address: -3 33 to Cross St Til\I <br /> DBA Mailing Address:133310IF 8$ City Lo C ,7[^ State: rA ZIP: <br /> Phone#: a 0q a 14%P.b Assessor Parcel Number(s): 0I 9 - <br /> Email: L.Oel +-+5 I . <br /> Other Businesses at this Address: <br /> Previous Business at Address: a,1A0 C C _ ft;r <br /> Description of Business Operation:: <br /> Type of Organization: 4 Single Owner ❑ Partrrership ❑ Corporation ❑ Other. <br /> Estimated Number of Full Time Employees: Estimated Number of Part Time or Seasonal Employees: <br /> Applicant Last Name: :t± Applipnt Frst Name: <br /> -Applicant Mailing Addmss:a-'�" ;i(I}c <br /> City State-tAi- 1 ZIPG 5710y Applin ant-Phone No: q_y 1,9—5-?pV J <br /> Water Supply: Public ❑ On-site Well Sewage Disposal: Public ❑ Septic System <br /> Will there be any sale of firearms? ❑ Yes P9 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 /> I,the Owner/Agent agree,to defend,indemnify,and hold harmless the County and its N 2'6\\iii,- <br /> agents,officers and employees from any claim,action or proceeding against the County <br /> arising from the Owner[Agent's project. <br /> WHealth <br /> SgnahueSTAFF USE ONLY <br /> : C f Zoning: - � UseType: rf,TME APPROVED DENIED DATE <br /> ervices Planner Name: <br /> tion //�'1�Health Div Or V-\ i.t'7 (077 <br /> Fire Warden MCIMWMW97 <br /> Public Works <br /> M.H.C.S,D. <br /> License Approved For. <br /> Remarks: <br /> 3 • _ r.3 Grp. <br /> Accepted as Complete: Date: <br /> F/AppficationsFDrms&Handouts/PlanningApplicationsBusiness License(Revised 02-2415) <br /> Page 2 of 6 <br />