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55B - RESO BRISTOL ST PROJ PHASE 4
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55B - RESO BRISTOL ST PROJ PHASE 4
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Last modified
5/3/2016 2:25:56 PM
Creation date
5/3/2016 2:20:49 PM
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City Clerk
Doc Type
Agenda Packet
Agency
Public Works
Item #
55B
Date
5/3/2016
Destruction Year
2021
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Non - Residential <br />Interview Form <br />❑ Owner ❑ Tenant ❑ Owner /Occupant <br />Interviewer: <br />Street Address: <br />Project Name: <br />Bristol Street Widening Phase IV between Warner <br />Ave. & St. Andrew Place <br />Property Owners: <br />Parcel Number: <br />Displacee: <br />Case Number: <br />Relocation Company: Epic land Solutions, Inc. <br />Unit Number: _ City: Zip: Date of Interview: <br />Business Occupancy Survey <br />1. <br />2. Primary Language Spoken in business: English ❑ Spanish ❑ Korean ❑ Other: <br />2a. In what language, other than English, do you request written material be submitted to you? <br />Spanish ❑ Korean ❑ Other: <br />3. Position with Business (Check all that apply): Owner ❑ Business Manager ❑ Employee ❑ Other: <br />vcuci ai uiivi uia uvu <br />4. Legal Business Name <br />I'NIP DVd; ll'. NT' t'Onik naam e a�iilll11 Ilea Rlwad for Caw (11 l n ilill aa on s II s k s (as ` pa � ve" <br />) a.r ., Ch ec bn an 11111 11 nr <br />maaada oR1I io I e naam e a llaI I n #sacra I h k 11i <br />aae Q dJ r ®' ainaallbe ruare u0 un IliianIad t o as COneallbuan# aacu sauaaat aaand aaaaa 11 caarOnr d° <br />5. Doing Business As (DBA): DBA registered? Yes ❑ No ❑ <br />6. Mailing Address (if different from street address, above): <br />City: <br />7. Phone No: Cell: Fax No: <br />Email <br />Zip: <br />8. Type of Business (Check all that apply): Retail ❑ Manufacturing ❑ Service ❑ Wholesale ❑ Other: <br />9. What is the business structure of your company? <br />9a. Sole Proprietorship ❑ Partnership ❑ Corp ❑ Franchise ❑ Non -Profit ❑ LLC ❑ <br />9b. Do you have any of the following? <br />Federal Tax Identification Number ❑ <br />Business License ❑ <br />Non - Profit Tax Exempt Status ❑ If so, what is the #? <br />9c. Federal Taxpayer Identification Number[:][:]-[:][:][:][:][:] <br />Social Security Number <br />Initials of Respondent: Initials of Interviewer <br />Page 1 of 11, Non - Residential Survey /Interview 55B-42 08114 <br />
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