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LG214 <br />(7r14'91) <br />Minnesota Lawful Gambling <br />Premises Permit Application Part 1 of 2 <br />FOR BOARD USE ONLY <br />BASE* <br />PP # <br />FEE <br />CHECK <br />INITIALS <br />DATE <br />Class of premises permit <br />Renewal (check one) <br />Organization base license number .❑ A ($400) Pull-tabs, tipboards, paddlewheels, raffles, bingo <br />Premises permit number B ($250) Pull -tabs, tipboards, paddlewheels, raffles <br />New ❑ C ($200) Bingo only <br />❑ D ($150) Raffles only <br />.W:Si::Q:<i;. 1::'•; .;..:;..;;..;.;..n:nY..,.;;S;Gy �n3ip� ...�M4w.,ly;:w..::::.....p.::Ni .. <.h a•R,»tC/ ;R <br />#organ ration= Orutationr <br />Name of Organization <br />L//"%L- G/9"Ai9D9i- 6/91( ' 9,2 -y, I- C - G /T7`/ -2- C,i`jpij , <br />Business Address of Organization - Street or P. 0 Box (Do not use th address of your gambling manager) <br />G-t7T/t GA7t -fP4 7 /%ti .92/77 � rfr755 y 6/. - -cal f -1/72 <br />City , . . State . Zip Code County / . Daytime phone number <br />-4-; y ,,:7U ref g g F t-L � RI,9 l.i 5/ 77— c6 /- tip- - feya <br />Name of of executive officer (cannot be your gambling manager) Title - Daytime phone number <br />Na ( Y ga n9 9 ) Y P <br />( ) <br />Bingo Occasions .... ... <br />If applying for a class A or C permit. fill in days and beginning & ending hours of bingo occasions: <br />No more than seven bingo occasions may be conducted by your organization per week. <br />Day Beginning/Ending Hours .... __.... Day __...,,__ Begtnntng/Ending Hours Day Beginning /Ending Hours <br />to to to <br />to <br />If bingo will not be conducted, check here <br />$milling enn1se4 rtfonnatipYL <br />ame of establishment where ambling will be conducted Street Address (do not use a post office box number) . <br />13apg 71 "T- gambling 1Z FAR_ . PL( RD L/'T L -Aph- <br />is the premises located within city limits? roYes CD No If no, is township ED organized 0 unorganized O unincorporated <br />City and County where gambling premises is located OR Township and County where gambling premises is located 0 outside of city limits <br />69ti/ga4.4 ( /yl/J e 7 i7 <br />and address f legal owner of premi s City State Zip Code <br />y/ o fl L/17//C 04v, A 1/4-57C LiY/ /e CL /'Q & L / f/ /� e iJ , hi t/ <br />Does your organization own the building where the gamb ng will be conducted? CD YES m NO s s-1/ 7 <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 D applications. <br />Address ,f storage space ofgairiibl ng equipment = Do ndt use a PO box umi er <br />Address City State Zip code <br />lcie t/l lG cgs -»iii- /?/- 55//9 <br />Page 6 <br />