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co ° APPLICATION - BUSINESS LICENSE <br /> y= I y SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> JUN 18 2014 <br /> •` '• BUSINESS LICENSE NO._ L' 4= <br /> cq�;oa`4 <br /> ENVIRONMENTAL HEA <br /> Lflj <br /> SERV <br /> TO'BE.COMPLETED BY THE APPLICANT PRIOR TO FILING THE APRLICATION' <br /> Business Information <br /> Business Name: �� 2 <br /> Business Address: 2 ;� Cross St <br /> DBA Mailing Address:11,1-Z O fN t City:jj 0(Xf 8 V) Stater ZIP: �� J <br /> Phone#0 72- 1()ZAssessor Parcel Number(s): &-Im CS, - <br /> Email: y C t j7 D!'1• Can <br /> Other Businesses at this Address: <br /> Previous Business at Address: <br /> Description of Business Operation:: <br /> Type of Organization: Single Owner ❑ Partnership ❑ Corporation ❑ Other. <br /> Estimated Number of Full Time Employees: Estimated Number of Part Time or Seasonal Employees: 0 <br /> Applicant Last Name: `(1 Applicant First Name:1 <br /> Applicant Mailing Address: f Z mod 5 <br /> city Z- s 11011-7 State ZIP Applicant Phone No: vq 7Z I o c/ <br /> Water Supply: ❑Public ❑ 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 /> 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 <br /> agents,officers and employees from any claim,action or proceeding against the County C, / <br /> arising from the Owner/Agent's project. <br /> Applicant's Signature. k_&&///v Lely. <br /> STAFF USE ONLY <br /> G/P Designation: C I C Zoning: —C Use Type: •a S Y L4 r, y,t <br /> DEPARTMENT APPRqVED DENIED <br /> DATE �H <br /> Development Services Ix Planner Name: I <br /> Building Inspection <br /> Environmental Health Div 5L4 0 610 i V") PVN , V11A04ti I c� ��• <br /> Fire Wardenj�- <br /> Public Works <br /> M.H.C.S.D. <br /> License Approved For. <br /> Remarks bb'of <br /> Occ.Grp. <br /> Accepted as Complete: Date: <br /> F/ApplicationsFonns&Handouts/PlanningApplications/Business License(Revised 11-14-11) <br /> Page 2 of 6 <br />