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FOR BOARD USE ONLY <br /> LG214 BASE# <br /> (7r"91) PP# <br /> FEE <br /> • Minnesota Lawful Gambling CHECK <br /> Premises Permit Application - Part 1 of 2 INITIALS <br /> DATE <br /> alto <br /> >R <br /> is <br /> ?1P e o q 1 <br /> ,f PP <br /> Class of premises permit <br /> Renewal (check one) <br /> Organization base license number C- ❑ A($400) Pull-tabs,tipboards,paddlewheels,raffles,bingo <br /> Premises permit number �`717 S —Col �B($250) Pull-tabs,tipboards,paddlewheels,raffles <br /> ❑ New ❑ C($200) Bingo only <br /> ❑ D($150) Raffles only <br /> :o a ; is:::: '%:::: ':' '::'':`:.'•::::�::::'<::':2:;: ;:: i'::•':::%::':?:`::::'`:::::`: °:::::::'::i:::::::<'':'':':':;i:' :::::::: ::::i::;:::':�::i'': ::::<:':'k: <br /> flr an>tza>hon:I rirn......:....:.::.:::.:::.:.:. <br /> :. <br /> gMiz a.. <br /> Name of Org izat'on <br /> S�. � &� J,I I S ors �S ��- ti <br /> Business Address of,Or ization-Str6ht or P.O Boo (Do not use the address of your gambling manager) <br /> 3 o r S t jV er <br /> City , State Zip Code County Daytime phone number <br /> :S,� I-`+ iuN � /v -�V/�? 9,-u'i--P, t/ (1:12-) <br /> Tmef chief executive officer(cannot be your gambling manager) Title Daytime phone number <br /> �/ „L (612-) C>Z/• 74;,2 j <br /> • Bingo Occasions <br /> If applying for a class A or C permit. fill in days and beginning & ending hours of bingo occasions: <br /> No more than seven bingo occasions may be conducted by your organization per week- <br /> Day Begiruiing/Ending Hours Day Beginning/Ending Hours Day Beginning/Ending Hours <br /> to to to <br /> to to to <br /> to If bingo will not be conducted.check hen <br /> ...5...... ....:..... .:..:::r:::::.:..::.::.}'!::yi:;:'S;;{:`;•SS:SSSS:S:XSS::??•:::%i;:%:::?.;yv. <br /> .. ... ... .. ... ., .: ..:: .. .. ...... .. .. ........... n.v•:...-:!.v:{.S4Si:hiS:y:.iv:.:. •S'.S: ??• <br /> S::'f.•i::i':iiiiifv••:•:'-Yii:ii.i:;::::'i:iijii$iS:•?:::•y:•:.$ii�:-ii <br /> ......... .........::.::::......:•.....:..v..... ... <br /> ::{.%:S::'i}i;{{.SSS.i;•.:v v:}:....{..{.:Sf-::v:;:;C:.�:::::W:!.v. <br /> 1.'.remises.:Infprmato . .........:..::...............................................:...:.:......:.:.....:.:::._.,.::::::::.:.,r..:.:.::.;:r...:rf ...:.:... <br /> Name sta lis meet where gambling will be conducted Street Address(do not use a post office box number) <br /> Is the premises located within city limits? Yes O No If no,is township 0 organized O unorganized O unincorporated <br /> City an/d County where gambling premises is located OR Township and County where gambling premises is located if outside of city limits <br /> Sl' . �A%V-10N / ! NrtlL%rf i✓ <br /> t rqq and address of/le'gal�Own f premises City S to ` �J / Zip Code <br /> l��c�-� S7� /�/.!��I`ti' .j; /t-7/1.f S.S <br /> Does your organization own the buildirA where 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 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 /> \vS <br /> Add ess of.S bra a:apace::of.:gamblin equipment oor,�r, �atot z ,mbef <br /> Address City State Zip code <br /> r Z /1�l;M CA) L r r s %td A), <br />