Application For Business License Form - City Of North Bend

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FOR CITY HALL USE ONLY
Application for Business License
ACCT. #______________AMT.PD$____________
1
FEE: $35/
st
YEAR (Jan-Dec)
CK#:______________ DATE:__________________
$25/Yearly Renewal (Jan-Dec)
Please print or type
**If business is a Home Occupation, read #16 below before completing application.
(1) Business Name
(3)
Federal E.I. #
_____
(4)
N. Bend Location Address
R
State of Washington UBI #:
(5)
E
Business Mailing Address: C/O
Number of Employees
Q
(6)
Street Address
Type of Business (check one):
U
City, state, zip
Individual
Corporation
I
Phone # (
)
Contact Name:
Partnership
LLC
R
(2)
Owner’s Name(s)
Other
E
(7)
Owner’s Street Address
Nature of business:
Retail
Service
D
City, state, zip
Manufacturing
Printing / Publishing
Phone # (
)
Wholesale
Contractor
Other
8)
IMPORTANT: Describe in detail the principal product or service rendered including the scope of business activity performed:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Does your business plan to operate or contract any physical location(s) in North Bend?
Yes
No
(9)
Is this business required by State Law to have any other licensing? Yes
No
A.) Washington State Contractor’s Registration Number:
Attach copy
B.) Washington State Liquor Control Board License Number:
Attach copy
C.) Other License/Registration Number:
Attach copy
(10)
Starting date of business in North Bend
, 20
(11)
If you purchased this business, did you take over entire business?
Portion?
Former owner’s name (if applicable)
Address
City, State, Zip
Phone #
(12)
Owner, partners, corporate officers and resident agents: (Attach separate sheet, if needed)
List true name(s), resident address, telephone number and date of birth of applicant if a sole owner or all partners if a partnership. If a
corporation, list all officers and directors, giving titles, and all stockholders who directly or indirectly control 25% or more of the company’s stock.
Name and Title
Resident Address
City, State, Zip
Phone #
(13)
List other business locations in North Bend:
Please complete an application for each location (Each license location = $35.00 fee)
Owner’s name
Location Address
City, State, Zip
Phone #
(14)
Tax reporting status – (check one)
Monthly: Taxable Gross Receipts will exceed $50,000 per month.
Quarterly: Taxable Gross Receipts will not exceed $50,000 per month
15
(
) Is this Business in your home? Yes
No
TYPE: Office use
Storage use
Sales use
Other
(16)
By signing below, I certify that the above information is true and correct and if this business is a Home Occupation I acknowledge that I
have read and agree to the “Special Rules for Home Occupation” (Addendum A). I also understand that approval of this Business
License does not constitute approval of operation in violation of any applicable city code(s) or permitting requirements (I.E. Signing,
Occupancy, Building, Grading, Etc.).
**Incomplete or inaccurate information may deny Business License.
Authorized Signature
and
Date
FOR CITY HALL USE ONLY
Out of Town
BUSINESS TYPE
DENIAL APPROVED
(Planning, Building, Fire)
DATE
HOME OCCUPATION
__________
PLANNING
COMMERCIAL
__________
BUILDING
OTHER/MISC.
__________
FIRE MARSHALL
(IF DENIED, Please complete an
__________
FINANCE
attached sheet)
LICENSE APPLICATION IS FOR:
NEW BUSINESS
RENEWAL
NAME / OWNERSHIP / ADDRESS CHANGE
PROCESSED BY
DATE
DATE LICENSE MAILED
→→→→→→→
Additional Information
03/29/07

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