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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property ACCEPTED BY: i;.Z v r'K .Ll, C -b FACILITY ID # BUSINESS NAME Living Spaces SERVICE REQUEST # Furniture Retail Showroom Em 713-9931 Neiv DATE: 17-/ -z-o t 6r I 1 OWNER / OPERATOR CITY La Mirada STATE CA Living Spaces CHECK If BILLING ADDRESS FACILITY NAME Living Spaces D� SITE ADDRESS 1355 VV Atherton Invoice # Manteca 95337 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 14501 Artesia Blvd. Street Number Street Name CITY La Mirada STATE CA ZIP 90638 PHONE #1 En. APN # LAND USE APPLICATION # (877) 266-7300 226-160-04 & 226-160-05 PHONE#2 Ear. ( ) BOS DISTRICTLOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Brian Saltikov ACCEPTED BY: i;.Z v r'K .Ll, C -b CHECK If BILLING ADDRESS BUSINESS NAME Living Spaces DATE: PHONE# 714 Em 713-9931 HOME or MAILING ADDRESS 14501 Artesia Blvd. DATE: 17-/ -z-o t 6r I FAX # ( ) CITY La Mirada STATE CA zip 90638 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. gss.w�v. APPLICANT'S SIGNATURE: Brian Saltikov m `� 12/17/19 DATE: PROPERTY/BUSINESS OWNER® OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT❑ I,ffAPPLICANT is not the BILLOJGPARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same It is provided to me or my representative. DA iq r� TYPE OF SERVICE REQUESTED: Zero Seat Food Permit COMMENTS: Install a 657sf kitchen to prepare sodas, coffee and bake frozen cookies as part Qf -44* 1. 120,000 sf retail furniture showroom. N✓o / h�crq['t'l�1j?o (/tIVC C � e c � 10.i/l � 7hy 4f, ACCEPTED BY: i;.Z v r'K .Ll, C -b EMPLOYEE #: DATE: ASsIGNEDTO: � +-.1 . EMPLOYEE#: DATE: 17-/ -z-o t 6r I Date Service Completed (if already completed): SERVICE CODE: S2-3 PIE: / &C) Fee Amount Amount Pai/o, D� Payment Date / 17 Payment Type �� Invoice # Check # I D.2—�G 147-3'Received By: EHD 48-02-025 REVISED 11/17/2003 fA %P14 C'—c�t,�f C vv -d PP -64^S SR FORM (Golden Rod)