HomeMy WebLinkAbout825 John Fitch Blvd - License - Fire Mar ` PLICATION FOR AUTOMOBILE DEALER'S DMV USE uCENSE NUMBER EXAMINER INITIALS
OR REPAIRER'S LICENSE STATE OF CONNECTICUT ONLY
K-7 REV.7-2016 DEPARTMENT OF MOTOR VEHICLES
DEALERS AND REPAIRERS SECTION
INSTRUCTIONS: On The Web At ct.govldmv
1.SECTION 1 must be completed by APPLICANT
2.SECTION 2 must be completed and signed by local authorities of the city or town in which the location is proposed.
3.Submit application and supporting documents to: DEPARTMENT OF MOTOR VEHICLES,DEALERS AND
REPAIRERS SECTION,SO STATE STREET,WETHERSFIELD,CT 05161-2011.
SECTION 1: BUSINESS INFORMATION
TYPE OF LICENSE o NEW CAR USED CAR GENERAL LIMITED
DEALER ❑ DEALIR REPAIRER ❑ REPAIRER
NAME UNDER WHICH BUSINESS OF A ANT IS TO BE CONDUCTED EMAIL ADDRESS
FULL ADDR OF LOCATION fort WCH LI ENSE S Qua D(Use separate application for each location)
MAILING ADDRESS,IF DIFFERENT FROM ABOVE
TYPE OF OWNERSHIP IF INCOR RATED OR LLC,UNDER LAWS OF WHICH STATE I DEEP PERMIT IF APPLICABLE
❑INDIVIDUAL ❑PARTNERSHIP ❑CORPORATION LC p h h e c, --
THE BUSINESS HOLDS A FACTORY FRANCHISE TO BELL THE FOLLOWING MAKE(S)OF VEHICLE(S)AT THE ABOVE LOCATION
If applicant firth is awned by individual or pannersttlp,enter data below for all owners. If owned by a corporation enter data for principal dram or major stockholders. If LLC,enter mergers end managers.
TITLE NAME HOME ADDRESS DATE OF BIRTH SEX
- 9glA s z L vU S4- f ef- y'-
rv1e.. ✓ Cvct �. Y►� ly -� s+r ��- -
Place a check mark in the box below,stating that you have no intention to apply for,nor have applied for a Manufacturer's license. Failure to check the box,will
result in a Dealer's or Repairer's license NOT being issued.
❑ 1 have not applied and do not intend to apply for a Manufacturer's license.
CERTIFICATION(To be signed by Owner,Partner,Managing Member,or Authorized Officer in presence of Notary)
Pursuant to CGS 53s-157b,1 SIGNED(O'nef,POI+ majorstocidrdderoraufharzedofted TITLE
declare that the statements made
by me in this application or in any X
documents attached hereto are Subscribed and sworn DATE SIGNED(Notary Public,Justice of Peace,orCommissionerofSupeAaCourt)
true and complete to the best of t0 before me: X
m knowledge and belief.
SECTION 2: CERTIFICATE OF LOCAL APPROVAL FOR PROPOSED LOCATION
Pursuant to CGS 14-54,local approval Is hereby granted for the above named firm or individual to conduct a business of the type checked below at the location
specified in this application.
Signatures of Building Official and Fire Marshal Indicate compliance with applicable laws and regulations.
Are there any restrictions placed on ❑the licensee's use of the property? NO ❑ YES(If'YES",a copy of the restrictions MUST be attached to this application.)
SIGNATURE OF AUTHORIZED OFFICIAL PRINT 7riLE DATE
X
TYPE OF BUSINESS APPROVED PROPOSED LOCATION ADJOINS
❑ ❑ GENERAL HIGHWAY STATE ❑ PAGE 1 OF
NEWCAR ELER ❑ I ❑ LOCAL
REPAIRER REPAIRER ROAD
DEALS SteNA7"L/P
t NB OFFICIAL PRINT
NiT TDA`T�E
NATU OF LCIN FI RSHAL ANT _ DATE