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<br /> <br />'¥ 10 - OU Upp /¡ 01!b uYl-fe.L pnJŒÞ i¿ ~ <br />APPLICATION FOR A LOCAL PE-RMIT OR CHARITY LOCAL PERMITilüw (];Urt:tLj tJ1!te¡' jOJ' <br />OFFICE OF ATTORNEY GENERAL *?fI'} <br />SFN 9338 (07-2003) <br /> <br />Application for: <br /> <br />.B(Local Permit <br /> <br />* 0 Charity Local Permit (one event per year) <br />Date(s) of Activity <br />vi' a J-O6 <br /> <br />Trtle CA PfeS, <br /> <br />Ci(;~ V\JLÝ <br /> <br />City . <br />Ga-~yt~V <br />Site Address <br />«'<Z Glž/}d VtU2 V <br />State Zip Code County <br />5'Çlo 3 & As 5 <br />* Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity LoCal Permit. <br />D Calendar Raffle D Sports Pool D Poker * 0 Twenty-one * <br /> <br />Person Responsible for the Gaming Operation, Including Disbursement of Net Income <br />Co n J1 \,¿ DiL \ l \L~ <br />Business Address <br />/&51' I / f 5r 5E <br />Mailing Address (if different) <br />~ElkMSo7I --- 1]D;t¡ <br /> <br />Name of Non-profit Organization <br />tJ (Jý'0- C <br /> <br />~LCA <br /> <br /> <br />Sf St2 <br /> <br /> <br />Check the Game(s) to <br />0 Bingo <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type Description of Prize Retail Value of <br /> Prize <br />KQ~.Ç l ~ <9L~1t $ 3 60, ó~ <br />, <br /> r ~ 0 S e... VY\ c.. 1.Ì2..d 5'0, tJo <br />1\ ,1: -re. W\ <br />, \ Kv\I'~~ Se..t :l~ òr. <br /> t <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Business Phone Number <br /> <br />'1~'I-5535 <br />State Zip Code <br />tv"O ~~3 (., <br />State Zip Code <br />J) , 5'rr CJ 3(0 <br /> <br />Nl> <br /> <br /> <br />D Paddlewheels. <br /> <br />Game Type Description of Prize Retail Value of <br /> Prize <br /> $ <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> (Umit$12,OOO per year) <br /> Total: $ L{ ~5. ~ <br /> , <br /> <br />Intended uses of gaming proceeds: <br /> <br />~.~~ <br /> <br />~Y-O~-e. ¿t5 <br /> <br />Does the organization presently have a state gaming Iicense~No Dyes - If "Yes," the organization is not eligible for a local permit or charity local <br />permit and should call the Office of Attorney General at 1-800-326-9240, <br /> <br />Has the organization received a charity local permit from this or another city or county for the fiscal year July 1 through June 30? d No DYes - If "Yes," <br />the organization does not qualify for a local permit or charity local permit '{'( <br /> <br />Has the organization received a local permit from this or another city or county for the fiscal year July 1 through June 30? M No Dyes - If "Yes," <br />indicate the total value of all prizes previously awarded: $ , This amount is part of the total prize limit of $12,at":Oper year. <br /> <br />Signature of Organization's Top Executive Official <br />~\ <br /> <br />Date ¿ <br />7 - 1:.;- 0 <br /> <br /> <br /> <br />Tit! n <br />Kh,\{".:(oJuELCA Ires ~~ <br /> <br />Business Phone Number <br />~- 5"556 <br />