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1 <br /> -3 <br /> APPLICATION - BUSINESS LICENSE <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1 :<I <br /> J BUSINESS LICENSE NO. // <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Business Information <br /> Business Name I N 8 C U S IOM L—v;1ci /• /_�� _ <br /> Business Address. 24 C.kJA T L v c,. IZt--) Cross St Ft"L_ , T <br /> DBA Mailing Address:�l{6, (,v A If 4 L,jo Ip City: State: ZIP:-(-j20 <br /> Phone 1t: 0 q) l D Assessor P reel Number(s). <br /> Email, 1A <br /> Other Businesses at this Address: <br /> Previous Business at Address: <br /> Description of Business Operation. 6tj <br /> Type of Organization: R Single Owner ❑ Partnership ❑ Corporation ❑ Other: <br /> Estimated Number of Full Time Employees. Estimated Number of Part Time or Seasonal Employees: <br /> Applicant Last Name: - A 0 Applicant First Name hA F©, AT <br /> Appl cant Mailing Address t.A t/>Lo O <br /> n <br /> City S_'7`­17(K'7-,- Stdte Ce" ZIF'� ,C Applicant Phone No. <br /> be <br /> Water Supply: ( L.I On-site Well _—_ Sewage Disposal: Public ❑ Septic System <br /> Wr':I there be any sale of firearms? ❑ Yes No <br /> NOTE: ANY CHANGE OF OCCUPANCY MA REQUIRE BUILDING IMPROVEMENTS AND NECESSARY BUILDING PERMITS. <br /> 1,affirm,under penalty of perjury that all the above information is true and correct I Date: <br /> I,the Owner/Agent agree,to defend,indemnify,and hold harmless the County and its <br /> i agents,officers and employees from any claim,action or proceeding against the County <br /> arising from the Owner/Agent's project. �� •}�J <br /> Applicdrit's Signature. <br /> STAFF USE ONLY <br /> GIP Designation: Zoning: <br /> DEPARTM NT APPROVED DENIED DATE <br /> Development Services Planner Name: <br /> Bwldmg Inspection <br /> Environmental Health Div <br /> Fire Warden <br /> Public Works <br /> M.H.C.S.D. Of <br /> t;cense Approved For: 7b ',-7;- <br /> Remarks: <br /> hTRemarks: C v� ��Q r <br /> i <br /> Occ.Grp. <br /> Accepted as Complete: Date: <br /> F 14)e.wc'Panning Application Forms'Bisiness License(Roysod 01-25-10) Pago 2 of 7 <br />