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innes ota'Lawful Gambling
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<br />..-,Leal§,er,far Pull-Tiab-Paddldwhciel",Tipb'6Ard,°"a'-n-W6 Raffl6a-A6tiv1,_UQ2,'& r'
<br />Name of Legal Owner of PremisesStreet Address City Daytime: Phony
<br />777
<br />Name -4 Lp DaylDaytimec,,'Lessor.-,. 'V
<br />Street Address
<br />.)
<br />(If same as legal owner, write In"S'WEE
<br />Name of Leased Premises - StreetAddress City. Zip Daytime Phone
<br />P0, hqut,i
<br />rgpnLzation leasing h Name of Lessee (nameof o tsing the premises), - GC13licenseno.ofoiganization*i, 'tDayti!Ti�P
<br />A=0_
<br />. .........
<br />0
<br />-ran not exc�6d �1;000'per' 3anization-,may,.not pay'rent to itself or..to
<br />or,
<br />_i'forsliace' d f6r-''t'h"'e 6onclu"'cl:
<br />activity or this premise afi�.'bi 6'affiljate use
<br />%fits-
<br />11�
<br />)A: '§Kqfr_h,"and 1b qqhkAk� ased,, ieP
<br />k
<br />UM
<br />areas ng, ease , or,, e.cqr) uc..� 11ca
<br />-gam Ing prcH dl . ROSS
<br />d�'66ia; kfif ih0%_
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<br />1prer 64z;'.
<br />ises,, c -shom etc
<br />HSI ec on a
<br />[L)Rased areas ,sand (2) on
<br />-dimenslofis-
<br />11
<br />Te rm-'of,,Le2
<br />I The 'tear'_ `6 t. ih i s
<br />it issued by the
<br />PaddlejA
<br />Fe.�'Iarge;print,` Braille)'
<br />dyla6alipilirij i.TTY'*Mc'
<br />t 1. 1-806-627-352T"a"ridasI
<br />R.911,reques
<br />,.call ifi6 Mih
<br />to Olace'a 6;
<br />a
<br />'feetf6f - 6 total
<br />Combiii6d totiftW�W-`'k.�*- T
<br />wN VA,
<br />7 W
<br />Zz.
<br />n_
<br />P u I I-Ta b es
<br />P
<br />:Amended Lease Oh
<br />e co n cU rre n t W1th the; ,,If "h* i s' i s a'n- a!mene'd lease changes' occurring dur-.-
<br />write: in. the
<br />Ang Control 'ing tfie_fiiftm of it 'Vri ,preTises perm
<br />ansent- of.the -Ie'_s"'o"r-"date"i that the'cha"hig-'e's will
<br />6o
<br />Both$grfi6s thatsigned the lease'mbst'ini0al'and' date all
<br />4;-
<br />change,�.
<br />4, 6,
<br />V
<br />.. '—M'.ti%-Q.�
<br />".-x
<br />fed to,theLicensingyThejif6rmation-reqypedoYffi iniill_b&�,us'.e..'d.
<br />'- by
<br />',the
<br />at4'(6i2)"�39-4000.h-Giibring Control Board (Board)to determine nQ�y9yr compliance{
<br />in alte e`form6t��- Wih n ruqS.gqVPT.V lii�l-pnSlihg
<br />.'HepringjMp�F�c"ctiv.tjBs:,AlCoihd'ihf6 t.on thatyDu-supply'6n thisjorm"
<br />,'�
<br />'6iota Relay SeM66M.will bec=6 oubrdJnfomationWhen receryed.bYhe. 36ardi_
<br />116 (612) 639-4000except, tfrequired, your Sbc*aI Sb-66tynumber,whichremains.
<br />private.i, ,:'-
<br />P ageA.of 2h
<br />x -Rev, 8/q7.,..,'
<br />
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