Laserfiche WebLink
Scrap Metal Dealer /Junk Dealer /Recycling Operation License Application <br />Page 2 <br />K. Are premises: Leased by applicant <br />If leased: Name of owner <br />Business address <br />III. PERSONAL DATA <br />A. Applicant's Legal Name <br />owned by applicant? <br />B. Residential A ss '�� /2 <br />City � <br />- State. Zip - 46 le <br />C <br />N <br />Residential Telephone Number <br />fl1.1 m7 %'tom <br />SSN <br />B. Date of Birth ��_ A - / 5:4 <br />IV. INCLUDE, WITH APPLICATION, A SITE PLAN OF THE FACILITY SHOWING <br />PROPERTY LINES, BUILDINGS, PARKING SPACES, LOADING DOCKS, FUEL <br />STORAGE, AND LANDSCAPING. <br />V <br />VI. <br />INCLUDE, WITH APPLICATION, A $5.00 PROCESSING FEE <br />AFFIRMATION <br />I, hereby, certify and affirm that all of the information 1 have given in this application is true and <br />accurate to the best of my knowledge. I further certify and affirm that I have in no way <br />attempted to mislead the City in this application by omitting facts known to me. I have read <br />and understand the regulations of the Scrap Metal Dealer /Junk Dealer /Recycling <br />Operation /Transfer Station license found in the City of South Bend Municipal Code, Section <br />4 -51. <br />&, (,IL", , /�,� I i —, 15- — /'0 <br />Signature <br />Date <br />