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APPLICATION — BUSINESS LICENSE <br />SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br />BUSINESS LICENSE NO. ID <br />TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br />Business Information <br />_ <br />Business Name: �f � m TI'Ch'191)1 SSi on -+'1 / r C <br />W Business Address: .-7C)49W 1 r Cross St C <br />DBA Mailing Address: � / City: ( State: n ZIP:C� <br />Phone # 2 ' Assessor Parcel Numher(s): L) - O <br />Email Y hs ►1'1 t G) Ico I n e, L I O . Y <br />Other Businesses at this Address: <br />Previous Business at Address: <br />Description of Business Operation L r <br />Type of Organization: ❑ Single Owner ❑ Partnership Corporation ❑ Other: <br />Estimated Number of Full Time Employees: Z <br />Estimated Number of Part Time or Seasonal Employees: <br />Applicant Last Name: a 6)1^— <br />Applicant First Name: k_ (_i✓ 1 <br />Applicant Mailing Address: LA-) • St <br />city L State r,. I ZIP <br />Applicant Phone No <br />Water Supply: ❑Public On-site Well <br />Sewage Disposal: ❑ Public & Sepdc System <br />Will there be any sale of firearms? ❑ Yes No <br />NOTE: ANY CHANGE OF OCCUPANCY MAY REOUIRE BUILDING IMPROVEMENTS AND NECESSARY BUILDING PERMITS. <br />I, affirm, under penalty of perjury that all the above information Is true and correct <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 pro <br />AppLcant's S gnaiUre ht ( 11 . <br />Date: <br />/ I <br />STAFF USE ONLY <br />G:P DesgratonLL Zer.:rG — Use Type. j /U/, - f C <br />DEPARTMENT APP VED DENIED DATE <br />Development Services Planner Name Z. L <br />Building Inspection <br />Environmental Health Div ZZ <br />Fire Warden <br />Public Works <br />M H.C.S.D. <br />License Approved For: <br />14 rYlti.► 3 torte lc� <br />Re m ark ; <br />Occ. Grp. <br />Acceotei as :: ,rp e:e Date' <br />F DevSvo.Plannr:g Application FOfms\Business Ucense (Revised o1-25-10) Page 2 of 7 <br />