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3992 BUSINESS LICENSE APPLICATION FORM
Send Completed Form To:
CITY OF LA QUINTA
BUSINESS LICENSE DIVISION
P.O. Box 1504
La Quinta, CA 92253
1. Business Name:-
2.
ame:2. Business Address:
65
BUS. LIC. NO.
005J.82 . i0 3377 ii -''3-9 i
J. CAZs -1 i TOTAL i 50.00
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3. Mailing Address: �� /5d X 71
z2p-&-�_2 �' e__5�.7 7/
4. Business Phone:
5. Owned By: CbRPORATION PARTNERSHIP�NDtVIDUA /L
• 6. If Corporation or Partnership: Tax I.D.#
7. If Individual Owner: Social Security # �7-
8 . Name of Owner or Officers and Title:
9. SBE Resale Number:
10. Number of Decals Needed: —�-
11% CONTRACTORS ONLY:
A. Type of Contractor:
--
B. Classification:
—7-
C. State License Number : , /-Z �� S
CONTRACTORS - GENERAL $100.00 Per Year or .00 Semi-annual
CONTRACTORS - SUB $ 50.00 Per Year or $25.00 Semi-annua
CONTRACTORS ARE ON A CALENDAR YEAR BASIS ONLY; ANNUAL FROM JANUARY 1ST
THROUGH DECEMBER 31ST. SEMI-ANNUAL FROM JANUARY 1ST THROUGH JUNE 30TH; OR
• JULY 1st THROUGH DECEMBER 31ST.
I HEREBY IFY hat a he information supplied by me is correct and
any li s r d the County, State or Federal Government have been
iss to" full ford and effect.
,-�/Signature
Title
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