*DATE OF APPLICATION: ____________________________

*NAME OF BUSINESS: _______________________________________________

*OWNER: ______________________________ *MANAGER: _______________________________

*TYPE OF BUSINESS:_______________________________________________________________________

*LOCATION: _________________________  *CITY/STATE/ZIP_______________________________

*LOCAL PHONE NUMBER: _______________ *BILLING PHONE NUMBER____________________

*BILLING ADDRESS: __________________________ *CITY/STATE/ZIP_______________________

*NUMBER OF FULL TIME EMPLOYEES: _________

*NUMBER OF PART TIME EMPLOYEES ______________

*SIGNATURE PERSON FILING APPLICATION                                                                        *Title                          

SALES □ MANUFACTURING □ SERVICE □ PROF. SERVICE □ RESTAURANTS □
RENTALS □ CHILD CARE □ CATALOG HOUSES □ 
CONTRACTORS, PLUMBERS & ELECTRICIANS □

CERTIFICATE OF OCCUPANCY # ___________________ SIGN PERMIT # _______________

BUILDING INSPECTOR
301 W. Chestnut Room #206
621-1100