Agenda - Council - 05/14/1991 - Laserfiche WebLink

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Premme Permit Application - Part 2 ' I ~ '"':~: '~ ' · ' ~'-~ '"< .......... Name of est~/iahment where gambling will be conduct~ 8treat Address (do not use a ~ost office box m/mber) I~' the premises lo, atari wilt/n dry limits? J~,ye~ . [] ~o I City and County where gamb/i~g premises is 1o__~:1_ OR Township and County where gambling premises i, lo~ted if outside of city limits Name and Address of Legal Owner of Premises '.:. · City State Zip Code I Does the organizal/o~ ow~ the building where Ihe gambling will be conducted? [] YES J~O I I I I NOTE: Organizations may not pay themselves rent if they own the building or have a holding company. A letter must be sub- mitred showing rent payments as zero from gambling funds if the organization's holding company owns the premises. The letter must be signed by the chief executive officer.) . . If NO, attach the following: Rent: ' a copy of the lease with terms for one year. ~ ' a copy of a sketch of the floor plan with dimensions, showing what portion is being leased. A lease and sketch are not required for Class D applicantions. ' ' ' For gambling with bingo $ For gambling without bingo $ ~(~,C:~,._~ Total square footage leased Total square footage leased I I I Address of storage space of gambling equipment Address City State D d~.~ ~~~.~<.~i~<:~<*~.~*~.~`:*:~e~.~`~:~:<~*~.:~.~`~ ,~ ..................................................................... ~.::.:::.,. ......................... ~:~ :.~:~: ....................... ~.- ..... (~ ~i~ gem~flng pmm~s m~t have a s~a~e ~king a~ou~t} ~ N~e ~k A~unt Numar ~k A~s Ci~ Sram ~p Co~ Narlle, a~dress, and title of persons authorized to sign checks and make deposits and wilhdrawal& Name Aclclress I I