BROWN•
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199.6 BUSINESS LICENSE APPLICATION FORM
BUS. LIC.. NO.
63
THIS BUSINESS LICENSE.. IS ONLY VALID - FOR. THE LA QUI14TA STREET FAIR - mew
......PROOF OF WORKERS COMPENSATION INSURANCE IS REQUIRED.........
APPROVED BY BUILDING & SAFETY DEPARTMENT
1. IS THIS BUSINESS LOCATED AT YOUR HOME:
2. Business Name:
YES f-- 11�" NO v-�"
3. Business Address: 4. Mailing Address:
5. Business Phone:(
6. Owned By: CORPORATION PARTNERSHIP INDIVIDUAL
7. If Corporation or Partnership: Tax I.D.#
8. If Individual Owner: Social Security #
9. Name of Owner ZQ'd . Title:
Or Officers /J
10. Type of Business:-- 4
11. SBE Resale Number: --�l4(2, 72k>S % 9
12. BUSINESS -LOCATED WITHIN THE CITY OF LA QUINTA (Does Not Apply To
Building Contractors).
A. -Estimated Gross Business Receipts for New Businesses Only:
S --
B. Previous Year Gross Receipts For Established Businesses:
3
********GOOD ONLY FOR JANUARY 1,19krTHRU DECEMBER 31,19*******
I HEREBY CERTIFY that all the information supplied by me is correct and
any licenses -required by the County, State or Federal Government have been
issued to me and are in full force and effect.
• Signa
Title
Submit Form -To:
CITY OF LA QUINTA
BUSINESS -LICENSE DIVISION
P.O. Box 1504
_ La Quinta, CA 92253
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