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LG214 <br />Minnesota Lawful Gambling <br />Premise Permit Application - Part 2 <br />SitabTf47/WienaTheilitfarinatfoxr. <br />Name conducted of establishment where gambling will be condud - Street Address (do not use a post atlas box number) <br />t'.. .Lr1t(i.Ca•aJa G -.1a 1.1411 11,40 Rea♦ St. •ukti.cC.` J, Wine SSI1') • <br />Is the premises located within city limits? Ca yes Q no <br />Giy and County where gambling premises is located CR Township and County where gambling premises is located if outside of city limits <br />L,AI <br />• <br />Name and Address of Legal Owner of Premises -'City .. . <br />Zp Code <br />SS /9 i <br />Ooes the organtzat>on own the bucking where the gambling will be conducted? OYES ®NO <br />NOTE: Organizations may not pay themselves rant if they own the building or have a holding company.' A letter must be sub- <br />,: rnitted showing rent payments as zero from gambling funds it the organization's hakiing company owns the premises. The <br />letter must be signed by the chief executive officer.) 1 <br />It NO, attach the following <br />• a copy of the lease with terms for 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 D appticantions. <br />Rent: <br />For gambling with bingo <br />$ 900 Sachs <br />For gambling without bingo $ <br />Address of storage space of gambling equipment <br />ss T dk J City ya_ <br />Ban eriimima'1 ibn <br />Total square footage leased 1 S, COO <br />Total square footage leased <br />State <br />Zp code <br />SSit7 <br />Z6 <br />(seco permursd sampling premises muse have • separate en•cnng aocounrj <br />Bank Name Bank Account Number <br />r t rrr�r <br />Bank Address <br />RI val l a r Obit( <br />9).a1I oG <br />City Stare <br />Rotnv,(1.a Minh, <br />Name. address, and Ode of persars aumaRad to sign checks and make deposits and withdrawals <br />((�� <br />Name <br />3v -e�j T Mz *soh 'a'")-14 (�ttlWee�/ loft v,t($ �kGCUT�Vi <br />869 F.Ccoa.*124 D <br />� h.dn.k � 0/11:tn: 105 • <br />Savc foto Gk.., <br />Skorc'vft,...c; <br />..'Toe 1..wv,Jcr5 3o3( e Avc..• Lift Ci aka M.,. SS /1 J <br />Zp Gooe <br />sstt3 <br />Address Title <br />P <br />Vtac'Pecs <br />Se. <br />• <br />