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APPLICATION - BUSINESS LICENSE <br />SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br />BUSINESS LICENSE NO. U C� 1, v 3 C <br />TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br />Business Information <br />Business Name t c <br />Business Addre� I_ Y Cross St 07t <br />DBA Mailing Addre5. City State: 6A— zlF <br />Phone # C i Assessor Parcel Number(s). C 1 <br />aG <br />Email. <br />Other Businesses at this Address. <br />Previous Business at Address <br />Type of Business <br />Type of Organization [Single Owner ❑ Partnership ❑ Corporation ❑ Other <br />Estimated Number of Full Time Employees. <br />Estimated Number of Part Time or Seasonal Employees <br />Applicant Last Name <br />Applicant First Name. 6 �. < <- x e %-- <br />Applicant Mailing Addres ll,y - <br />r" <br />ZIPr' Applicant Phone No: <br />City!E State C <br />Water Supply tALPublic ❑ On-site Well <br />Sewage Disposal Ou Public ❑ Septic System <br />Will there be any safe of firearms? ❑ Yes 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 <br />I, the Owner/Agent agree, to defend, indemnify, and hold harmless the County and its <br />agents, officers and employees from any claim, actionor proceeding against the County <br />arising from the Owner/Agent's project. <br />1/7 <br />Applicant's Signature rlr <br />Date <br />STAFF USE ONLY <br />GIP Designation � Zoning- — <br />Use Type: I ��tf <br />s� « �; <br />AIr�- <br />DEPARTMENT APPROVED DENIED <br />DATE <br />Development Services <br />Planner Name <br />-30 <br />Building Inspection <br />Environmental Health Div <br />l0 <br />Fire Warden 7 r0C.K{brJ <br />O()U <br />Public Works <br />MHC.SD. <br />License Approved For <br />C1 Lice A 1 4(L t/-—, <br />Remarks <br />i (t C-0- 1 OU I <br />Occ. Grp <br />Accepted as Complete <br />Date. <br />F 1DevSvcTlanning Application Forms\Business License (Revised 11-16-09) Page 2 of 7 <br />Wit LT <br />