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OFFICIAL USE ONLY BUSINESS CERTIFICATE NO EXPIRATION DATE TOTAL PAID $ □ CASH □ CHECK CITY CODE SIC CODE ISSUING CLERK REVIEWD/APPROVED BY: Initial/Date Planning □ Yes □ No Police □ Yes □ No Building □ Yes □ No Environmental □ Yes □ No Fire □ Yes □ No Health □ Yes □ No Other □ Yes □ No Estimated Gross Receipts For Next 12 Months $ No. of Rate Employees Schedule Business Tax Fee Due $ Application Fee $ 36.00 State CASp Fee $ 4.00 Balance Due $ New Application □ Change of Owner/Location □ Altering Structure □ □Yes □ No □Yes □ No □Yes □ No ● Please Check All That Apply ● 8353 Sierra Avenue ● Fontana, CA 92335 ● (909) 350-7675 ● Attn: Business License Disclosure of your U.S. Social Security Number is mandatory on this application. Public Law 94-455 (42 USC 405(2)(C) authorizes collection of your social security number. Your social security number will be used exclusively for tax enforcement purposes. Owner Name Title Phone ( ) Home Address Birthdate City State Zip Social Security No. Driver’s License No. Owner Name Title Phone ( ) Home Address Birthdate City State Zip Social Security No. Driver’s License No. PLEASE FILL IN THE APPROPRIATE BOXES BELOW AND SIGN NOTICE: 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 www.ccda.ca.gov Sales or use tax may apply to your business activities. You may seek written advice regarding the application of tax to your particular business by writing to the nearest State Board of Equalization office. For general information please call the Board of Equalization at: 1-[PHONE REDACTED] NOTICE Business certificates are issued pending the approval of any or all of the above named Regulatory Departments. Preliminary filing of this application does not constitute evidence that the above described business has met the requirements of the Fontana City Code or Regulatory Agencies of the City of Fontana. Home Based Business □ Yes □ No If yes, mail and phone location only. FOR HOME BASED BUSINESSES, THERE IS TO BE NO STORAGE, SIGNS, EMPLOYEES, IN/OUT TRAFFIC, LARGE VEHICLES. PLEASE INITIAL THAT YOU HAVE READ: I declare under penalty of perjury that this application and any attachments thereto, have been examined by me, and to the best of my knowledge and belief represent a true, correct and complete statement of facts. Signature Title Date Business Name Business Address (P.O. Box NOT Allowed) City State Zip Mailing Address City State Zip Business Phone ( ) Business Fax ( ) Email If business address is located within the City of Fontana please complete 1 thru 4 1. Previous use of building 2. Does use involve hazardous or highly flammable materials? 3. Do you operate more than one business at this location? 4. Are you currently property owner of business location? Describe EXACT Nature of Business (Various Businesses require Police Clearance) Ownership: □ Corporation □ Corp-Ltd Liability □ Sole Proprietor □ Partnership □ Trust Resale/Sellers No. Federal I.D. No. State I.D. No. Contractors State License No. License Type Expiration Date SIGN ---PAGE BREAK--- Tax Rate Schedule (Gross Receipts) The following tax rates shall be applicable to every business declared to be subject to a tax based upon gross receipts, and such taxes shall be subject to annual review and adjustment by council action. TAX RATE SCHEDULE A TAX RATE SCHEDULE D If Gross Receipts Are: The Tax Is: If Gross Receipts Are: The Tax Is: Under $50,000.00 $52.00 Under $50,000.00 $100.00 Over $50,000.00 $52.00 plus Over $50,000.00 $100.00 plus $0.25 for each thousand dollars or fraction thereof over $50,000 $1.00 for each thousand dollars or fraction thereof over $50,000 TAX RATE SCHEDULE B TAX RATE SCHEDULE E If Gross Receipts Are: The Tax Is: If Gross Receipts Are: The Tax Is: Under $25,000.00 $26.00 Under $25,000.00 $52.00 Over $25,000.00 $26.00 plus Over $25,000.00 $52.00 plus $0.30 for each thousand dollars or fraction thereof over $25,000 $1.00 for each thousand dollars or fraction thereof over $25,000 TAX RATE SCHEDULE C TAX RATE SCHEDULE F If Gross Receipts Are: The Tax Is: If Gross Receipts Are: The Tax Is: Under $100,000.00 $78.00 Under $25,000.00 $26.00 Over $100,000.00 $78.00 plus Over $25,000.00 $26.00 plus $0.75 for each thousand dollars or fraction thereof over $100,000 $1.00 for each thousand dollars or fraction thereof over $25,000 CONTRACTORS LICENSE DECLARATION Section 1. Section 7033. Every city or city and county which require the Issuance of a business license as condition precedent to engaging within the city or city and county, in a business which is subject to regulation under this chapter, shall require that each licensee and applicant for issuance or renewal of such license shall file, or have on file, with such city or city and county, a signed statement that such licensee or applicant is licensed under the provisions of this chapter, and stating that the license is in full force and effect, or if such licensee or applicant is except from the provisions of this chapter, he shall furnish proof of the facts which entitle him to such exemption. This is to certify that the undersigned is licensed under the Business and Professions Code of California as a Contractor and that such license is in full force and effect. Date Signature Title This is to certify that the undersigned claims exemption from the provisions of Section 7000 ET.SEQ. of the Business and Professions Code, in that I propose not to furnish labor and/or materials on any project, the value of which (aggregate labor and materials) is over $1,000.00. Date Signature Title WORKERS’ COMPENSATION DECLARATION I HEREBY AFFIRM, UNDER PENALTY OF PERJURY, ONE OF THE FOLLOWING DECLARATION: I have and will maintain a certificate of consent to self‐insure for workers compensation, as provided by Section 370, for the duration of any business activities conducted for which this license is issued. I have and will maintain workers’ compensation insurance, as required by Section 3700, for the duration of any business Activities for which this license is issued. My workers’ compensation insurance carrier and policy number are: Carrier Policy Number I certify that in the performance of any business activities for which this license is issued I shall not employ any person in any manner so as to become subject to the workers’ compensation laws of California, and agree that if I should become subject to the workers’ compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with the provisions of Section 3700. Date Applicant WARNING: FAILURE TO SECURE WORKERS’ COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000 IN ADDITION TO THE COST OF COMPENSATION DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST AND ATTORNEYS FEES. To do business with the City of Fontana please register your business/company at: www.fontanapurchasing.org SIGN SIGN