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LG214 <br />(7w91) <br />Minnesota Lawful Gambling <br />Premises Permit Application - Part 1 of 2 <br />Type of Application <br />FOR BOARD USE ONLY <br />BASE # <br />PP8 <br />FEE <br />CHECK <br />INITIALS <br />DATE <br />Renewal <br />Organization base license number <br />Premises permit number <br />New <br />Organization informatt <br />Name of Organization <br />/ IM& 0.k JAD Let orfbJ k%CIC <br />Business Address of Organization - Street or P. 0 Box (Do not use the address of your gambling manager) <br />Class of premises permit <br />(check one) <br />A ($400) Pull -tabs, tipboards, paddlewheels, raffles, bingo <br />B ($250) Pull -tabs, tipboards, paddlewheels, raffles <br />❑ C ($200) Bingo only <br />❑ D ($150) Raffles only <br />(5)55 c, i i i CA-0 o iC.D. <br />City State <br />nt d fn) ADA• M <br />Name of chief executive officer (cannot be your gambling manager) <br />Bingo ' a s kit-d-(0/0 <br />OC cs on <br />Zip Code County <br />SSA '7 IC A-MS E-1 <br />Tide <br />Daytime phone number <br />46,1,) L.f4L -.2 t'7 7 <br />Daytime phone number <br />(4p(2) t4k'u- 4/G, <br />If applying for a class A or C permit, fill in days and beginning & ending hours of bingo occasions: <br />No more than seven bingo occasions may be conducted by your organizatiort per week. <br />Day Beginning/Ending Hours Day Beginning/Ending Hours Day Beginning /Ending Hours <br />to <br />to <br />to <br />Gambling Premises Information <br />Name of establishment where gambling will be conducted <br />LSfgXDA) AAJr- <br />to <br />to <br />If bingo will not be conducted, check here <br />to <br />to <br />Street Address (do not use a post 9,ffice box number <br />% / //./Z/41.- e���_ <br />Is the premises located within city limits? (Sir Yes = No If no, is township organized unorganized 0 unincorporated <br />City and County where gambling premises is located OR Township and County where gambling premises is located if outside of city limits <br />Name and address of gI owner of premises City State <br />/0 V / �// <br />L( -raE. 40A <br />Zip Code <br />Does your organization ownithe building where the gambling will . • conducted? = YES pZj N <br />If no, attach the following: <br />• a copy of the lease (form LG202) with terms for at least one year. <br />• a copy of a sketch of the floor plan with dimensions, showing what portion is being leased. <br />A lease and sketch are not required for Class 0 applications. <br />Address of storage space of gambling equipment - 'Do not use a PO box number <br />Address City y,`OJ State Zip code <br />de na-d - %'fl,t- V`^J> /7 <br />Page 70 <br />