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13. Treasurer/ Member__________________________________________________SSN#______________________

Home Address_____________________________________ Apt# _____City __________State _____Zip_______

Home Phone(

)_________________D/O/B___/___/___/Drivers License #_____________________State_______

14. Person completing application________________________Cell #_______________Title______________________

15. Name of manager(s) of this location_________________________________________________________________

16. Have you the applicant, or anyone having any ownership of this business ever violated, been arrested, or convicted of

any Federal or State Law, or any ordinance or resolution regulating any business?_____ If yes, please list all dates and

locations of the offenses and disposition of charges_________________________________________________

______________________________________________________________________________________________

17. Are you, the applicant the corporation, LLC or any shareholder currently delinquent in payment of any taxes or fees to

any state or local government?_____

___ If yes, Please indicate the type of tax or fee, and the amount due with the reason the tax

is delinquent. ______________________________________________________________________________________________

__________________________________________________________________________________________________________

f this property is zoned residential, no clients,

I swear or affirm that I have obtained or will obtain

employees, sales, deliveries, storage of inventory,

within sixty days of the date of this application a Cobb

or equipment are allowed on the premises. Only

County Certificate of Occupancy as required by State

one commercial vehicle not to exceed 12,500 pounds

law for the address listed on this application. I further

gross weight used as transportation by the occupant

understand I will call the Fire Marshal’s office with

may be parked at the residence.

any questions regarding a Certificate of Occupancy at

(770) 528-8310.

I will comply with the Zoning

Restrictions stated above: _________

Signature: _____________________________________

(initials)

I, ______________________________, affirm that the facts stated by me are true, I understand any misrepresentation or

fraudulent statement is grounds for automatic dismissal of this application and/ or revocation of the license. I understand

that all signs displayed on my premise must be permitted by the Cobb County Community Development Agency. I further

understand that my business must be operated in compliance with all applicable state, federal & local laws, ordinances &

regulations, & that the granting of this occupation tax certificate or payment of this occupation tax does not waive the right

of any federal, state or local entity to regulate & enforce such laws, ordinances & regulations.

This _____ day of ______________________, 20___.

Signature of applicant_____________________________________________________________________________

( ) Owner ( ) Manager ( ) Other specify _________________

THIS APPLICATION IS SUBJECT TO THE APPROVAL OF THE FIRE PREVENTION BUREAU AND/ OR

THE DEPARTMENT AND INSPECTIONS DIVISION.

OFFICE USE ONLY:

Occ. Tax Cert. # ____________________________ SIC # ___________Category_____ BL STAFF___________________

Due current yr________________ Due previous yr________________ Due for 2 yrs prior to current yr______________

Penalty_______________ Interest ____________ Total Due$____________ Receipt #____________

Method of payment: CASH / CHECK #________________ Zoning Division _________________________ Approved/Denied

(circle one )

REVISED 2/10

Precious Metal Application For Corporation Or Limited Liability Company Llc Occupation Tax Certificate Form - Cobb County Business License Division Page 2

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