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FOR BOARD USE ONLY <br /> LG214 BASE# <br /> vr'sq'1 PP# <br /> FEE <br /> • Minnesota Lawful Gambling CHECK <br /> Premises Permit Application - Part 1 of 2 INITIALS <br /> Class of premises permit <br /> Renewal (check one) <br /> Organization base license number 0,-),941s. ❑ A($400) Pull-tabs,tipboards,paddlewheels,raffles,bingo <br /> Premises permit number Q.29-vs — QO Z B($250) Pull-tabs,tipboards,paddlewheels,raffles <br /> ❑ New ❑ C($200) Bingo only <br /> ❑ D($150) Raffles only <br /> :.:.:.::::.. •:::,:......,....,. :..,:....u.........:.::..::.........:...:......: <br /> .... ...................... .... .................................. .......:v: w:............................... xr:+{>:}v:??.}}:ti:::h:i-:ti?i:::•Y: <br /> ::::..........................::.::::......}:}i::•}:}iY}Y:':i is{•:{?iiYi:i}i:-}}:{4:{fi:{:?:}:4ii:-i:•;+{<{{:}':::}• <br /> ..{:.iF{i?.}}}ii}i is?.:?�:?�}}}}}:::::'i:•}:{.ii}:4:?.}}ii'•}i::?:•}�:}}:�:{-:is <br /> `^/'��� /.•::•'%-}i:i}ii}i}:iii:•:?.....................:. ...... ...r.. <br /> . - •.. Ilr`�/���'`:{!i:}•}:•!::iii:-}is:�iiiii:'}:::i+i}}i::.}:iii:4:Y:•:}}::4i:•}?::Y::•i:L}}:9ii:v4:b}i+ <br /> ar anlzahon:r o...rma........:....::.:.::.::::......................:..:::::::::.::�::::::.:::.:::.::.::..........::.:..:.:..�:.,r:::::.:�. . <br /> .N a of Or iza on <br /> • rJoN l 07 orS o <br /> Business Address of Org nization-Streellor P.O,,Box(Do not use the address of your g bung manager) <br /> O ( Si� Jar Ca �'c/4= <br /> Cl- State Zip Code County Daytime phone number <br /> •j0 A)Aa1j A4 rJ SSy le /yr�u,�r (bi zi 78� <br /> 1 5410 e of chief executiivee o r(cannot be your gambling manager) a Daytime pphone number <br /> ( _ 1 I�/'d I►^�Cr" �res i 4 J C (612.)%02/ <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 Begiradng/Endtng Hours Day BegLnning/Ending Hours Day Beginning/Ending Hours <br /> to to to <br /> to to to <br /> to If bingo will not be conducted.check here <br /> .. �:.r.: :::.:.:. ::•a:..rr..-::i.r�,.rr..:r.•;uv.,.w..;•>r. i::.::<::,.:is{.?..:a.:.::r:...i:.; <br /> :•ir,{?... .-:,i• s{v.c 'ji•R :L;F:; +{.RF} .Ra•{ <br /> ...... •.......:..... ....n.:n.. .... ................ .v:.,...v:.�:... •:..�:::::••.�:.x.:..n.. n...............;-}................f.....::.w:::-:•.v...•u:?'di;.}}}`:•}i:•::.} <br /> :{•:{.v-^i:;i:4:Ti.�YY'-0:J <br /> ROM v}:{}•iY::•YY ::: :M:w:.v::{:}..:...:.........¢ ••Yi}:v;v. <br /> [}riff{!!:is4}}i}}:{O}:4}}i"Y�:i?•}::{{^:14::•.v::::..�::: 4i'f :•�:v i:h.:.r::•i'•i:'i•in+:}: <br /> >. sinb <: 'remises:::Ian`firma. .. ...................:..............::..r.....:. <br /> Na e o establishment where ambling will be conducted t Address(oo not u a post office box um er) <br /> aC'A l cJa✓ s D Sf/ r� La,F r� - .�.�iU ,,., <br /> Is the premises located within city limits? A Yes O No If no,is township O organized ED unorganized p unin rated <br /> City and County where gambling premises is located OR Township and County where gambling premises is located if outside of city limits <br /> Na nd address of le al owner of mises City State Tip Code <br /> 7Z e' N y, 33 o S./a« La k,_ 2cl- <br /> Does yout organization own the building the gambling will be conducted? p YES NO <br /> If no,attach the following: <br /> • a copy of the lease(form LG202)with terms for at least one y ar. <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 of..sto :.Yes ace of sa><blin .:e, ui ment::-oe'riofiisa PO boiE'i;imber .;:._ <br /> Address City State Zip code <br /> • Z—J21,�+i �S/ r S'`�' .SJ�• 12 uJ N<<,/ &Or'54►fie J- I"nJ <br />