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LG214 <br />(7/29/91) <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 />Renewal <br />Organization base license number ,(3-o38or, <br />Premises permit number <br />New <br />Organization.:.TiOT7�L..: <br />Name of Organization <br />Class of premises permit <br />(check one) <br />A ($400) Pull -tabs, tipboards, paddlewheels, raffles, bingo <br />OB ($250) Pull -tabs, tipboards, paddlewheels, raffles <br />n C ($200) Bingo only <br />11 <br />D ($150) Raffles only <br />Business Address of Organization - Street or P. 0 Box (Do not use the address of your gambling manager) <br />,C7/ 5z7/ <br />City State Zip Code County <br />5:9 /747 JSoZS---- <br />Name of chief executive officerfi(caann be your gambling manager) Title <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 Beginning/Ending Hours Day Beginning /Ending Hours <br />Daytime phone number <br />fG/Z) i�G V <br />Daytime phone number <br />(G/2) <br />to <br />to to <br />If bingo will not be conducted, check here <br />to <br />reg willStreet Address(do not use a post office box number <br />.::..�:.:•;:,•>:......,,,>.»„>::.::........................ <br />Name of establish�jent where gambling be conducted <br />< Sty 4' �. /, 'S //V 5---,5-0/V <br />Is the premises located within city limits? l'Yes O No If no, is township f—I organized I--1 unorganized El 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 legal owner of premises City <br />State <br />• <br />/1/c, c, 7 4 ‘ibb % /4caS Z , :t o !v c -c r t_j <br />Does your organization own the building where the gambling will be conducted? <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 />I--1 YES i>zi NO <br />Zip Code <br />....................................................................... <br />....................... <br />eq <br />uipznen , <br />........................................... <br />Address <br />City <br />State Zip code <br />