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ka r.I V r.L) APPLICATION - BUSINESS LICENSE <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> N <br /> NOV 09 2015 <br /> BUSINESS LICENSE NO.,�. <br /> NVIRONMENTAL HEALTH <br /> PERMI I ISEFIVICE57— <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Business Information <br /> Business Name—�ga 1.. BE A q IN � <br /> Business Address: Cross St Ojrv �A�,w i <br /> �, ,r", 9, <br /> DBA Mailing Address;: S(.11 L S;ack�y too R.A city. z 40n State- ii�zlp: <br /> Phone : Q <br /> Assessor Parcel Number(s): <br /> ctal at4-4 <br /> Email: UxossQin SA" (2 4�PQlk-Lam- <br /> L:Eer Businesses at this Address: <br /> Previous Business at Address: <br /> Description of Business Operation:", <br /> Type of Organization: C1 Single Owner ❑ Partnership Iffsrporation El Other. <br /> Estimated Number of Futl Time Employees: 2. Estimated Number of Part Time or Seasonal Employees: <br /> Applicant Last Name: 4�ssc;, Applicant First Name: <br /> on Uisba <br /> Applicant Mailing Address:Srg <br /> City —t-A .%LState ZIP-qwI-Is Applicant Phone No: LAO 43 S %Q <br /> Water Supply- <blic, E3 On-site Well Sewage Disposal: RRO-Public El Septic System <br /> Will there be any sale of firearms? [] Yes P-<O— <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 information is true and correct Date: <br /> 1,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/Aant's project. <br /> Applicant's Signature: <br /> STAFF USE ONLY <br /> GIP Designation.�/L- Zoning: — Use Type:4 <br /> DEPARTMENT APPROVED DENIED DATE <br /> Development Services Planner A AA <br /> Building Inspection <br /> Environmental Health Div QL-7y-1 S t'i, 104 0-11 <br /> Fire Warden ',/aJ/WL <br /> Public Works <br /> M.H.C.S.D. <br /> License Approved Fore Y <br /> //7Q a& <br /> LL--rki e2 ot a a-S- Q QQag <br /> Occ.Grp. <br /> Accepted as Complete: Date: <br /> F/Applicabons Form s&H andouts(Planning4pticationstBusiness License(Revised 02-2415) <br /> Page 2 of 6 <br />