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Uate of application �t•y-YL <br />B1SINESS NAME'1�;;q{^1/-^v^_[PIIOIJE <br />/1 BUSINESS ADDRESS!7L-i4"_—•_------_--•--- <br />(strcct) <br />c i.tv)-_.---- <br />—_.. (suf!) 17.1p <br />OWNERS/CORPORATE OFFICLIZS/ASSOCIATES/I'AI('1'NIil(S (name a title) <br />211 l/�a ew 7Y - C� If <br />_ ABM (eACPN �A1`� <br />HAVE YOU EVER HAD A LICENSE REVOKED? V6 if yes, attach explanation. <br />TYPE OF LICENSE REQUESTED: Li45 �/ ` �11'i-e SAv s — r9Y3 <br />REFERENCES: CITIES WHERE PREVIOUSLY OR CURRENTLY LICENSED FOR SAME <br />ACTIVITY (name of city and year(s) licensed) <br />LOCATION FOR WHICH LICENSE IS REQUESTED (if applicable) <br />OWNER OF PREMISES (if applicable) <br />Applicants for the following license must complete the applicable section <br />on the reverse side of this form: <br />amusement devices/bingo/bowling alleys/dance halls/ garbage <br />collection/gasoline stations/kennels/peddlers/solicitors/ <br />restaurants. <br />I hereby certify that information provided on this application is true <br />and correct and understand that any misrepresentation made herein may <br />be grounds for denial of this application. <br />Applicant's name #j •• •f If/ e,. F1;DS Lac!.__ Date of birth dcr6 <br />(please print) <br />Applicant's signs <br />v Date of Council approval License number <br />New Renewal _ <br />(rev. 5/77) <br />