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BUS—LIC. NO.
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ulft�Gv
.1991 BUSINESS LICENSE APPLICATION FORM P,l 0
************** ******************* * **************************
*APPROVED INITIALS- DATE
*DENIED INITIALS DATE
1. IS THIS BUSINESS LOCATED AT YOUR HOME: YES NO
2. Business Name:
3. Business Address: Mailing Address: d .BQW9 r,Ql/
5. Business Phone:( '
6. Owned By: CORPORATION PARTNERSHIP INDIVIDUAL
7. If Corporation or Partnership: Tax I.D.#
8. If Individual Owner: Social Security # �502-76 -30,
9. Name of Owner �u71/L� /! Title: OGyN
Or Officers
10. Type of Business:0,e.2 1� . —ILL, 25 ✓all 6-A-'
11. SBE Resale Number:
12. BUSINESS LOCATED WITHIN THE CITY OF LA QUINTAi
Building Contractors):
owisW;tT 1� To ii8:00 14
A. Estimated Gross Business Receipts for New Businesses Only:
,-Ra 0
B. Previous Year Gross Receipts For Established Businesses:
********GOOD ONLY FOR JANUARY 111991 THRU DECEMBER 31,1991*******
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.
15
Signature Title NOV Date
. 1991
Submit Form To: C'TyOFUQul
CITY OF LA QUINTA cnlHMu"�7YSAFETyVC
BUSINESS LICENSE DIVISION
P.O. Box 1504
La Quintal CA 92253
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