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01/24/2013 12:32 FAX 209 831 6439 CITY OF TRACY zi!L TRACY Administrative Services Dept -1F 333 Civic Center plaza, Tracy, CA. Fisoal year July Leto June 301' IM 002/002 C. pee— 4nance Maid: (209) 831.6800 2013 cc Fax: (209) 831-6846 DS Fax: (209) 831-6439 "Under federal and state law, compliance with disabili ac ass la ' ' ioouus and sf guoant responsibility that applies to all California building owners and tenants wi open to the public. You may obtain information about your leegal obligations and how to comply wllh disability access laws at the following agencies; The Division of the State Architect nt mw,daca ttov/dsgMgMg aspg The Department of Rehabilitation at www.mhab.cahwnet.gov The California Commission on Disability ,A,coess at www.ccda,ca, og_v" ❑ $1.00 Statemandated fee J 'Nevi► Business ' ❑ Home'Oedoation A Namb Change : S1 Ownership Chjj�lle ❑ Address Chance ' Business Name -ACC. fefyoftumi'C - 6 0 - TXT cj a Yo Owner. 116LLQ� M r SS on OMMesS 1Loc$tpoea (cannot be a Po �Bo�x type) 4 37 N, e Ka A.ddres8 0 `i .. 6 A J«, 4A f= .. JAM &0'16 „'—��. i ve�,n oY�, J Business Phone j - La,- 5 7 .0o C UEmergency phone 9 A 5'-115 Description of business activity (include detailed fn formatlois such as dates, Jobslte, products) C” oaS S ion Br G SI., -de- Business e Start date 7lA)r2cy, _M &Ae,4 ITe-mail (opaoaaq Resale t1 # o �- 3 er 54f, SEIN# 'ALT State CoxxtWior >LiG # Claes J�plres Other LIC/P nn►it_ e w rI !C Peddlers/ceneral contractors 11 Annual r Qtr July -Sept [3 Q Octtr2 Dec 133'd Qtr dan Ivfar ❑ '4Qtr Apr -June WCO Health Permit# Expires ' Temp Use ]Permit # Number of owners i of full-tim rs 4. of part-time/workers (less than 32 brs) � Am you 4A Ind dent agent or rent space at this location? ❑ Yes 0 No # of Delivery Vehicles (pmtTracy) As part of Us license, do you prep , sell or serve food? P1 Yes 0 No Ili of Rental units Tracy) Do you deal with F° ? ❑ Yes M No DOJ# _ Est. annual gross Vending machines N/f} Is massaLge therapy conducted at flats location? ❑ Yes No Ila you deal with second-hand ? ❑ Yes [a No O'WNz ' i • lit Corporation" ❑ f LC: ❑ peez4uerlhip 'U 9oie°Propdetor" ❑ Non Profit . ❑ ,Othg Name of ownirkddal address & personal I.D. of awners & peattiers;_if pjp car; *T50445. not redatred. 1.Owners Name jia i nti S • M ; S1 p Address A.57 a Ca~ 61 o cA 14-5,0G Drivers ?L1cdW .... Sot. Sec. # (C24e9t be PO Typo lees) Contact 2, Owners Name SOC. SBC. # contact o _ 3.Own era Nam Address JA% l ` 13 (Caaeot be 1'O Type Box). Drivers 1,!c 1ID Soo. Sec. # Contact i#... . Ideck" under Penalty of PedW that the i►} amtadox contained In this appMeadon Is trace and correct to the bast of nW knowledge, and their on andwrized to campl¢te this application. Irtders Vote .fun d that once this application is submlKe4 the !kation fee and the ma> dated fee is non�tndahle, 1110 11 :1 , ff- SIPEN"r -_ 7b Title Signature of Owner or Representative BL Tax Cert. # Do not write in space below- City use only (City will issue) ❑ Adv Q �-- 13 ❑ Pxewt M Peddler Q1 Q2 Q3 Q4 ❑ Home Occ NAIC3/SIC Amuse ❑ Outside ❑ Ra ud ❑ Per Employee �� C3 Card Table M Contractor 13 Pdmisoy Q 1 Q2 Q3 Q4 [ISOlkhor d Vending ❑ Sheet KusJJ3ztt ❑ Xmas" Owner(s) FT pT 13):)Y— ❑ Transfer/Change ❑ State SBI186.fee collected A App fes Amount !laid $� ......._.......... rAReceived Time5hn.24.en2013 11:40AM No.2161 Ip:Ftnance front, counte Pa9e:002 R=ify