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FOR OFFICE USE ONLY: <br />ACCOUNT # <br />CUSTOMER ID # <br />LICENCE REF # <br />CLASS <br />CITY OF S TO C K 0 N: <br />ADMINISTRATIVE SERVICES DEPARTMENT <br />REVENUE SERVICES DIVISION—BUSINESS LICENSE TAX 425 <br />North El Dorado Street- PO Box 1570 • Stockton, CA • 95201 <br />Phone (209) 937-8313 <br />Email: <br />BUSINESS LICENSE TAX APPLICATION <br />NEW LIC Fel Number of Employees: Full Time I Part Time Temporary Square Footage <br />CHANGE 0 Change From Date of Change Bus Lic # <br />NOTE: Any change in ownership, address, or business activity, requires a new application. The City of Stockton does not <br />guarantee that information on this form will be exempt from disclosure under the Public Records Act. <br />BUSINESS INFORMATION: <br />Business Name (DBA) '3 0)12-e g.t6c cda-tai 2-1 Phone ( ) 0 Cr - 9 5 I I <br />Business Address 't!) 1%,1A1L-1 P.( ett-S DI2 Ste/Apt #1 2- City ,S CAr--TONState C1A Zip 952-11 <br />(Cannot be PO Box per CA Bus & Prof Code Section 17538.5) (List address where each individual consent to receive service of process A82184 Sec 1600.) <br />Business Mailing Address Ste/Apt # City State Zip <br />(If different from the service process address/Business address) <br />Business Email Address 10Q11 RA r- I t•-4 c.,F-A Z-1 I(;)iAKaQ• CA M <br />Business involved in renting residential or commercial real estate (Stockton only): <br />Property Address <br />Property Owner Parcel # <br />Detail Description of Business Activity CJ OTTAC4 e FOOD Off P-'s T I ciK./ <br />Standard Industrial Classification (SIC): Major Group: <br />Are you Chamber of Commerce Green Certified? Yes FIN <br />(For information contact Chamber of Commerce (209) 547-2770) <br />Start date in the City of Stockton 1 II1 12-1 Estimated Monthly Gross Receipts in Stockton $ <br />Contractor's only: Project Amount CA Contractor's License # <br />Classification Expiration Date <br /> <br />El Annual E Quarterly Contractors License <br /> <br />Seller's Permit # SS# or Tax ID # <br />Check One: Single Owner E Partnership L7 Corporation E LP I: LLC <br />OWNER(S) INFORMATION: (The following personal information is not public and will not be shared in accordance with city policy OL-103.) Proof of <br />compliance with Business and Professions Code Section 17538.5(b)(2)(A)(B) may be submitted in lieu of home address. <br />Name I?) 12-1 T TAN-1 F3A 12-N ----T-T Address 6 6 ,5 1 M Al2-Ir-I ei'-- •-.0 D 12-- APT ---1 2__ <br />CitySTOG1,--Iat..) State G A Zip 15 2-1 1 Home Phone (2-01 40 Lc - 15 I 1 <br />Date of Birth % III 11'1 Driver's Lic or Other I.D.# F-9—I 9 09 3 -1 State CA <br />Name Address <br />City State Zip Home Phone ( ) <br />Date of Birth Driver's Lic or Other I.D.# State