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LG214 Premises Permit Application <br />FOR BOARD USE ONLY <br />Check # <br />Organization Information <br />$ <br />Organization name Cu Mb f License number 0 0 a <br />I Daytimephone " T3 9a <br />Chief PE IA.) Ul57 <br />Gambling Premises Information <br />Name of establishment where gambling will be conducted 44T Z E <br />Street address where premises is located 'a / Lf-f Hit / / <br />(Do not use a P.O. box number or mailing address) <br />7 Ci i Township <br />,> Py1 S O I R <br />County <br />RAJ4, <br />Zip code <br />5 5 36 3 <br />Does your organization own the building where the gambling will be conducted? <br />Yes t-410 If no, attach LG215 Lease for Lawful Gambling Activity <br />Gambling Bank Account Information (must be in Minnesota) <br />Bank name Bank account number <br />W el-- F »e2 q9 7 4. Ii • <br />Bank street address Cit St ate /Z c ode ] a 1 <br />' d0 - 0a6A.S1� 5 - 1J <br />All Temporary and Permanent Off -site Storage Spaces <br />(for gambling equipment and records related to this site - must be stored in Minnesota) <br />Address (D not use a P.O. b x n umber) ty co e <br />&' f$ CA n om Ci <br />Ii ti Give mA.) s <br />Bingo Occasions (including bar bingo) <br />Enter day and beginning /ending hours of bingo occasions (indicate A.M. or P.M.). An occasion may not exceed 8 hours. <br />Day Beginning /Ending Hours Day Beginnina /Ending Hours <br />- PA C 9 : D QO�m to q Prim to <br />f to to <br />to to <br />t to <br />to to <br />to to <br />t to <br />to to <br />to to <br />to to <br />to to <br />Annual Fee $150 <br />6/07 Page 1 of 2 <br />