Pleasanton Business License Application

General Business Information

Business Name/DBA:*
Attention
Business Address:*
City* State* Zip*

Same as Business Address

Mailing Address*
Mailing City* Mailing State* Mailing Zip*

Business Phone* Business Website:
Emergency Contact Name:* Emergency Contact Phone #:*
Business Start Date:*

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Organization Type:*

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Business Description:*

Please select the business type that matches your's best.*

select

Please select your NAIC code from the list

select

OWNER NAME/HOME ADDRESS:

LIST ALL OWNERS INFO or LLC/CORP- LIST CORP OFFICERS

Contact 1

Title1*

select

Name1*
Address1*
City1* State1* Zip1*
Phone1* E-Mail*
SSN1 Driver's License Number1

Contact 2

Title2

select

Name2
Address2
City2 State2 Zip2
Phone2 E-Mail
SSN2 Driver's License Number2

Contact 3

Title3

select

Name3
Address3
City3 State3 Zip3
Phone3 E-Mail
SSN3 Driver's License Number3

Additional Business Information

Provide the following when applicable:

California State Sales Tax Number/Resale # Sein
Fein

Number of Employees*

State Contractor License Number State Contractor Expiration

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Project Name and Address:

Total Project Value:

Estimated Gross Receipts

This license period is for twelve months ending

Estimated Gross Receipts are based on months

Please enter your estimated gross receipt:*

*State Mandated Fee ($1.00) for Disability Access & Education Revolving Fund:

On September 19, 2012, Governor Brown signed into law Senate Bill 1186, adding a state fee of $1.00 to any application or renewal for a business license/permit, effective January 1, 2013. This fee will provide a funding source for increased education on disability access and compliance with construction-related accessibility requirements to facilitate compliance with the federal and state disability laws.

Under federal and state law, compliance with disability access laws is a serious and significant responsibility that applies to all California building owners and tenants with buildings open to the public. You may obtain information about your legal obligations and how to comply with disability access laws at the following agencies:

• The Division of the State Architect at www.dgs.ca.gov/dsa/home/aspx
• The Department of Rehabilitation at www.rehab.cahwnet.gov.
• The California Commission on Disability Access at http://www.ccda.ca.gov .

Agreement

I declare under penalty of making a false certification that the foregoing information is true and correct to the best of my knowledge and belief.

Executed this I, By submitting this application I accept the conditions and declare under penalty of perjury the foregoing is true and correct.

Please sign your name below, using the mouse or your touch screen enabled device.

General Business Information

OWNER NAME/HOME ADDRESS:

Contact 1

Contact 2

Contact 3

Additional Business Information

Estimated Gross Receipts

Renewal Notice Delivery Method

Agreement