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<br />Minnesota Lawful Gambling <br /> <br />Lease for Pull-Tab, Paddlewheel, Tipboard, and/or Raffle Activity - LG221 <br />Name of Legal Owner of Premises Street Address City State Zip Daytime Phone <br /> <br />O-{....... /Ce.- ,/1 7701' 2&"" #r.L/AOA_t= h""v S::>c/I' ~/-C;S7-&e 70 <br />Name of Lessor Street Address City State Zip Daytime Phone <br />(If same as legal owner, write in "SAME") <br />A"r4r{ r U..fi--/",.-f' ?BY? Cc..,h.~~./k ~ ;"~~,,,/k /"/VYJo38 65"h:5'5 1/87 <br />Name of Leased Premises Street Address City Zip Daytime Phone <br /> <br />w~'5""c..-, J A'Zz.""o-Ar,j 7ot's a' i4cJ '::Cr.!/-FicY'ifi/lc- ~.I/.Q-G> 6,:,{'-C;Y3 {077 <br />Name of Lessee (name of organization leasing the premises) GCB license no, of organization Daytime Phone <br />!Jei;.f g;b.{:",. ~ c,b..? 13'-03B= <;-s-/- ~~- 7Z.2-::, <br /> <br />Rent Information <br /> <br />. Total rent cannot exceed $1,000 per month for all <br />non-bingo activfiy for this premises, <br /> <br />. For bingo activity, use lease form LG222. <br /> <br />. For pull-tab dispensing machines, use lease form <br />LG223. <br /> <br />. 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 -I).) <br /> <br />/00 <br /> <br />feet by B feet for a total of L/rB 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 />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: 6 <br /> <br />Storage <br />Storage <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 />o Paddlewheels ~UII-Tabs lZIRaffles ~bOardS <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----C.' 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 />Section of the Gambling Control Board (Board) at 651-639- <br />4000. This publication will be made available in alternative <br />format (Le. large print, Braille) upon request. Hearing impaired <br />individuals USing a T1Y may call the Minnesota Relay Service <br />at 1-800-627-3529 and ask to place a call to 651-639-4000. <br /> <br />The information requested on this form will 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 /> <br />Page 1 of 2 <br />1/99 <br />