41 W 2nd Street BTR 5-8-14 CITY OF ATLANTIC BEACH
4
I J* 800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233
LOCAL BUSINESS TAX APPLICATION
Section 1 .
APPLICATION FOR �New Business iQ ans fer Ownership ❑Transfer New Location:Previous location
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BUSINESS NAME Q C a- ✓� + 3 2z3
LOCATION ADDRESS .3
MAILING ADDRESS /
1 + D' FAX CELL
BUSINESS PHONE 1
EMAIL ADDRESS
NATURE OF HE BUSINESS(Please Be Specific) p N
Alb bIr 66�2�7)
SQUARE FOOTAGE OF BUSINESS PREMISES 3J~ S
(Include both buildings and outside areas used in conjunction with the business,but not patron parking areas)
NUMBER&TYPE OF VENDING MACHINES(if any) N
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Section 2 GE.�
APPLICANT/LOCAL MANAGER/PRINCIPAL OFFICER 2
HOME ADDRESS S � TAZ F
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HOME PHONE 9�y ��& O 7'l SS#or Fed Employer ID# i +
DATE OF BIRTH 7' ro
DRIVER'S LICENSE# R a o 3 S 0 6 O O QAttach copy)
STATE LICENSE/CERTIFICATION/REGISTRATION It(if applicable,attach copy)
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Section 3
I,the undersigned,swear that the above statements are true and correct and I agree to notify the City Clerk if there is any change in the
above information. lieves me of the
I further understand that ions octl of Cade of Ordinances Receipt by the City
to conducting lra way re the City of Atlantic Reach.responsibility of
compliant with all provisions of
Title
Signature
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----' -A&1(d -�( Ap G�S Date
PRINT NAME
No person,firm or corporation shall engage in or lit age and/ordaybment does not econstitute approval or isuance of a receipt.out
first obtaining a Local Business Tax Receipt.App p
Section 4(For Office Use Only) $100.00-Zoning/Building Fee Paid on_ Business Tax Receipt#
❑FULL YR ❑HALF YR Business Tax Amount $ cation
_—
Code#&Classifi
[]Health Cert#
El Fictitious Name Reg. [I Corporation Reg. El State Reg/Cert/Lic#
OTHER Requ' Comrnis ion Approv 1 Yes No Approved/denied by Commission on
DATE I
ZONING APPROVED BY ` DATE
BUILDING DEPT APPROVED B DATE
FIRE DEPT APPROVED BY DATE
CITY CLERK APPROVED B
V �
ss Name:
Last Business Use: lec'(Ron� F�tMP1' Last Busine