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<br />Lawful Gambling . i'i
<br />
<br />,or Pull-Tab, Paddlewheel, Tipboard, and/or Raffle Activity - LG221
<br />
<br />Street Address C,y State Zip Daytime Phone
<br />
<br />707 Zor(,~", J-rP"I:. ffi4/' C.5/-~53' 861<
<br />Name of Lessor Street Address C,y State Zip Daytime Phone
<br />(If same as legal owner, write in "SAME") J'L1# ....._
<br />
<br />k-:-...."rf( ~ y~ A-,- ",~-t. ':'8?z c<'..h---""If' dc~,,>4,.-,-,./lS50J6'CO--;-~53-/18'l
<br />Name of Leased Premises Street Address City Zip qay1!me Phone
<br />
<br />LV;s" .<?z<-" w-~ '0'1.> zoffl1'<-"',5 c"",,,-;;',...If'c /7;</5",:;036 bY/..S3/077'
<br />Name 0 essee (name of organization leasing the premises) GCB license no. of organization Daytime Phone
<br />c",.P' .3rd"" Y;/H.-.- c,,{.5 8-036'00 ;y/-f!'-72Z--5~
<br />
<br />Rent Information
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<br />, .
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<br />feet by B feet for a total of f/8 square feet.
<br />feet by feet for a total of square feet
<br />feet by feet for a total of square feet
<br />feet by feet for a total of square feet
<br />feet by feet for a total of square feet
<br /> Combined total square feet.
<br />
<br />o Total rent cannot exceed $1,000 per month for all
<br />non-bingo activity for this premises.
<br />
<br />orar bingbactivity, use lease form LG222,
<br />
<br />For pull-tab dispensing machines, use lease form
<br />LG223,
<br />
<br />Sketch and Dimensions of Leased Area
<br />
<br />Sketch: For all areas being leased for the conduct
<br />of gambling and storage of gambling product at this
<br />premises, attach a sketch (drawing) showing: (1) the
<br />leased area(s), and (2) the dimensions,
<br />
<br />Dimensions /.
<br />The leased areas are: (.#
<br />
<br />Storage
<br />Storage
<br />
<br />o An organization may not pay rent to itself or to
<br />any of its affiliates for space used for the conduct
<br />of lawful gambling,
<br />
<br />Rent to be paid per month $
<br />(If no rent is to be paid, indicate -0-)
<br />
<br />/00
<br />
<br />= .
<br />-
<br />
<br />For Premises Permit Renewal Applications Only: If no
<br />changes have been made at the site, you do not have to
<br />complete this section or provide a sketch,
<br />
<br />Lawful Gambling Activity
<br />Type of gambling activity that will be conducted at this gambling premises, Check all that apply,
<br />
<br />rn Paddlewheels IKI Pull-Tabs ~ Raffles Tipboards
<br />Term of Lease Amended Lease Only
<br />
<br />The term of this lease agreement will be concurrent with
<br />the premises permit issued by the Gambling Control
<br />Board, unless terminated sooner by mutual consent of
<br />the lessor and lessee,
<br />
<br />If this is an amended lease showing changes occur-
<br />ring during the term of the current premises permit,
<br />write in the date that the changes will be effective
<br />_1_1_, Both parties that signed the lease
<br />must initial and date all changes,
<br />
<br />Questions on this form should be directed to the Licensing
<br />eclion of the Gambling Control Board (Board) at 651-639-
<br />4000. This publication will be made available in alternative
<br />formal (i.e, large print, Braille) upon request. Hearing impaired
<br />individuals using a TIY may call the Minnesota Relay Service
<br />at 1.800-627-3529 and ask to place a cail to 651-639-4000,
<br />
<br />The information requested on this form wiil become public
<br />information when received by the Board, and will be used to
<br />determine your compliance with Minnesota statutes and rules
<br />governing lawful gambling activities,
<br />
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