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APPLICATION — BUSINESS LICENSE <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 0. i V <br /> BUSINESS LICENSE NO, 3,k— <br /> ............. <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Business Information <br /> Business Name: A <br /> Business Address: 2(0(0� ti wit s4y, Cross St <br /> DBA Mailing Address 21LA02 A/ W0 0^ P'V� Z.q) <br /> Phonek 97 y Assessor Parcel Number(Q, <br /> Emare <br /> Other Businesses at this Address: <br /> Previous Business at Address <br /> Desc,iption of Business Operation.. kV-1- 1Z, v <br /> Type ofOrganization Single Owner D Partnership El Corporation C1 other, <br /> Estimated Number of Full Time Employees Estimated Number of Part Time of Seasonal Employees: <br /> Applicant Last Name: 1 Applicant First Name: <br /> Applicant Mailing Address. 2_C,(p2 V\),\k5,0V\ Wc,,i <br /> City State LNk ZIP ,q�_10'5_1 Applicantokihone No, <br /> Water Supply PPublic 0 On-site Well sewage Disposal, O-Public 0 Septic System <br /> Will there be any sale of firearms? 0 Yes :2 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 infonnation is true and correct Dole, <br /> 1,the Owner/Agent agree,to defend,indemnify,and hold harmless the County and Its <br /> agents,officers and employees from any cl ion or procee 'ng gainst the County <br /> t!s from at <br /> arising from the Owner/Agent's employees <br /> Applicant's Signature <br /> SE ONLY <br /> GIP Designation: Zoning: C VO plv— <br /> DEPARTMENT A 1^1 <br /> ,P-P,RqVED DENIED DATF <br /> L--A ay I <br /> Development Services PlannerName <br /> Building Inspection z <br /> ,Environments!Health Div <br /> Fire Warden <br /> Public Works <br /> M H C.S.D. <br /> License Approve IWO > I A�,)91 <br /> Remarks )W V)O\ 7iT <br /> Occ Gro, <br /> Accepted as Complete. Date <br /> F 1DevSv6Planning Application FormskBusineSS Lteense(Revised 7.14.11) Page 2 of 8 <br />