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APPLICATION BUSINESS LICENSE <br /> SAN JOAQUIN COUNTY COMMUNITY'DEVELOPMENT DEPARTMENT <br /> f . MAR 0 2 2016 Lpbuv53 <br /> ENVIRONMENTAL HEALTH <br /> BUSINESS LICENSE NO. �,' I <br /> •Q?ii:;:e>�/ PERMITISERVICES <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Business Information <br /> [Emai <br /> ness Name: <br /> ness Address: 3 Gross St <br /> Mailing Address: ` 1 City C State: (aq• ZIP('� y <br /> ne#:?Eq,"�•Z .� Assessor Parcel Number(s): <br /> r Businesses at this Address: <br /> ious Business at Address: <br /> Description of Business Operation:'"` L <br /> Type of Organization: 9 Single Owner ❑ Partnership ❑ Corporation ❑ Other. <br /> Estimated Number of Full Time Employees: Estimated Number of Part Time or Seasonal Employees: <br /> Applicant Last Name: r Applicant First Name: A n <br /> -Applicant Mailing Address: �Le <br /> Cityl_ e State{.^— Z1P .5-a--4. Applicant-Phone No: 'Z;0*1.4,:� -40(p( <br /> Water Supply: Wublic ❑ On-site Well Sewage Disposal: 91,'Public -❑ Septic System <br /> Will there be any sale of firearms? ❑ Yes 5j�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 <br /> agents,officers and employees from any claim,action or proceeding against the County <br /> arising from the Owner/Agent's roject. <br /> Applicant's Signature: <br /> STAFF USE ONLY <br /> GIP Designation: Zoning: (; "C, Use Type: 0 ` ,�(�C�' ��ki✓rnt1 .� <br /> DEPARTMENT APPROVED DENIED DATE <br /> Development Services 07 Planner Name: (' <br /> Building Inspection <br /> Environmental Health Div V 75_ A—16 <br /> Fre Wardenmo <br /> Public Works <br /> M.H.C.S.D. <br /> License Approved For. � D ✓i� - f}l; t'Y1(�(li j f 1� V10►ti/J u-92, <br /> A <br /> Remarks: e/ 1. ' 13 1J1`�`}' -IDDM �• pQjbv3to� - D2'DU � <br /> •�q-p;�13 �, .vl�-Obfl� -ft3-��-• .v-�b3-t ��l-1 <br /> Occ.Grp. <br /> Accepted as Complete: Date: <br /> F/ApplicationsForms&Handouts/PtanningApplicafionsBusiness License(Revised 02-2415) <br /> Page 2 of 6 <br />