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r� SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT OCT 1 G 2017 BUSINESS LICENSE NO. �L-- I-7c)oz_? �NVIR0NMEWAL HEALTIJ TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION Business Information Business Name: Busmess Address: �-f 3 3 .r DBA Mailing Address:( City: State+ ZIP: yjZ Phone #: S( Assessor Parcel Number(s): PV3 - Z .- T Email: GL ✓� 1413 'ZSO - D Other Businesses at this Address: Previous Business at Address: Description of Business Operation:: ,�� ::5 Type of Organization: ❑ Single Owner ❑ Partnership VCorporation ❑ Other. Estimated Number of Full Time Employees:FCEstimated Number of Part Time or Seasonal Employees: Applicant last Name: Applicant First Name: Applicant Mailing Address: City t` StateG,4 ZIP Applicant Phone No: 2 Water Supply: public ❑ On-site Well Sewage Disposal: [Public ❑ Septic System ,,/. Will there be any sale of firearms? [I2 Yes No NOTE: ANY CHANGE OF OCCUPANCY MAY REQUIRE BUILDING IMPROVEMENTS AND NECESSARY BUILDING PERMITS. I, affirm, under penalty of perjury that all the above information is true and correct I, the Owner/Agent agree, to defend, indemnify, and hold harmless the County and its agents, officers and employees from any claim, action or proceeding against the County arising from the Owner/Agent's project. Applicant's Signature: Date: q [[ ✓ �(% _z�l� STAFF USE ONLY G/P Designation: • Zoning: Use Type: CJe1l,,£',*'�:2_ (' I`XK, L-,fY ieL I - L4 I'Vl1 ec,[ DEPARTMENT APPROVED DENIED DATE Development Services Planner Name: - Z - Building Inspection Environmental Health Div /, - SU 0V it 26 - Fire Fire Warden Public Works M.H.C.S.D. License Approved For. A ems. I k L S Gil Remarks: L,( X96 -0b X31 L -Il_ 143 -'2A0 �t'q7-uZl� Occ. Grp. Accepted as Complete: Date: F/ApplicationsFonnsBHandouts/PlanningApplicationsBusiness License (Revised 02-2415) Page 3 of 7