MEDINA0
•
PAID NOV 1 5 1991 ..
BUS—LIC. - NO
44'
.19`91 BUSINESS LICENSE APPLICATION FORM
*APPROVED INITIALS DATE
*DENIED INITIALS DATE
1. IS THIS BUSINESS'LOCATED AT YOUR HOME:
A,
2. Business Name: rn f j -pqa A
3. Business Address ✓��a� 4 •
5. Business Phone:(-)_
YES_ 'NO_
i
Mailing Address: ,5;7�
6. Owned By: CORPORATION PARTNERSHIP INDIVIDUAL 1
7. If Corporation or Partnership: Tax I.D.#
8. If Individual Owner: Social Security. # 6 J
9. Name of Owneren
Title:
Or Officers
10. Type of Business: adz,
11. SBE Resale Number:- - T
12. BUSINESS- LOCATED WITHIN THE CITY OF•LA-QUINTAi�
t tors ) $A� }s 8i'1� � YiS�,ii8 00 i0
+�, � ' • �F�
Building Con. rac . - , ,
A. Estimated Gross Business Receipto, for New Businesses Only• /
$
tir
r
B. Previous Year Gross Receipts For Established Businesses:
$
********GOOD ONLY FOR JANUARY 111991 THRU DECEMBER 31,1991*******
tion
lied by me is
I HEREBY CERTIFY that alltheeCount�aState orpFederal Governmentehavenbeen
any licenses required by Y
issued to me and.are in full force and-�efiect.
a
Signature iiti
le
Submit Form To:
CITY OF LA QUINTA
BUSINESS LICENSE DIVISION
P.O. Box 1504
La Quinta, CA 92253
to
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