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io <br />• <br />• <br />8/05 <br />Page 1 of 2 <br />LG214 Premises Permit Application <br />(see Required Attachments on Page 2) Annual Fee $150 <br />FOR BOARD USE ONLY <br />Check# $ <br />Organization information <br />Organization name Organization license number <br />Gc44nn,`w / Y *L }14, c -4 7 4ssoc. 03934 <br />Name of chief executive officer (CEO) Daytime contact phone number <br />1 --;sow 14c•c -L--t , + 71 ,3 •- 7cS'.1'— 7p r, <br />rNot the mailing address. <br />Do not use a P.O. box number. J <br />Street address where premises is located <br />goo i L„kt blue. <br />premises information <br />Gambling P <br />Name of establishment where gambling will be conducted <br />/II, /I-e r...f a. Pi "net .,e <br />City / Township <br />L�v,c LA�e s ICRI <br />County <br />%nok0. <br />Zip code <br />.sue —d/ y <br />Does your organization own the building where the gambling wi <br />Yes ,�,No If no, attach LG215 Lease for Lawful Gambling <br />I be conducted? <br />Activity <br />Gambling bank account information <br />Bank name Bank account number <br />Bank street address City State/Zip code <br />Flol Mnel41 -e l c Aloe . 1111;" e7 4 A.100 i s mN 3'..s' y4?: <br />Address(es) in Minnesota of all temporary and permanent off -site storage space for gambling <br />equipment and records related to this site (may not be stored outside of Minnesota) <br />Address (Do not use a P.O. box number) City State /Zip code <br />9442 o Al. ,1.s _s4. N • e : 1 1ai., r. i v n N .5,3° ‘7"1 9 <br />Bingo occasions (including bar bingo) <br />Enter day and beginning /ending hours of bingo occasions (indicate <br />Beginning /Ending Hours <br />A.M. or P.M.). <br />11a <br />An occasion may not exceed 8 hours. <br />Beoinningandina Hours <br />DalC <br />Ai. 4- 14,446- ,. y .i+ , <br />T asc/a�.�r <br />to <br />to to <br />to to <br />to to <br />to to <br />to to <br />to to <br />to to <br />to to <br />to to <br />t0 t0 <br />to t0 <br />