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<br />, <br /> <br />Minnesota Lawful Gambling <br />Lease for Pull-Tab, Paddlewheel, Tipboard, and/or Raffle Activity - LG221 <br /> <br />Name of Legal Owner of Premises Street Address City State Zip Daytime Phone <br />.rJ f L-r;;: /. &5/0 Ce..t7-~./lc #,..f L'~~ .t..~{~.> C5f-{lZ? 2'j j <br />,rez..<./. i' oqr-&.;z......_ //2/ L033 <br />Name of lessor Street Address City Slate Zip Daytime Phone <br />(If same as legal owner, write in "SAME") <br />,54: "" c.- <br />Name of Lea$ed Premises Street Address City Zip Daytime Phone <br />-;r/b z-;. r'-- 708~ Cc:"",/-~p-;~C' "f-e: (-::C'''"'k~?/./I /f'p<:r503b ,(,51-0'.-21' 5 <br />Name of Lessee (name af organization leasing the premises) GCB license no. of organization Daytime Phone - <br />J;7-~..f7 L',;.~", i-e _"i...~Uk c.b..J 8-0.J80~ cJ-I- ~;: $I 7ZZ.5"' <br />' ~- <br /> <br />Rent Information <br /> <br />-.;:,' <br /> <br />-c;; <br /> <br />. Total rent cannot exceed $1,000 per month for all <br />non-bingo activity for this premises. l <br /> <br />. For bingo activity, use lease form LG222. <br /> <br />. For pull-tab dispensing machines, use lease forf\l <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 />~ <br /> <br />8 <br /> <br />feet by <br />feet by <br />feet by <br />feet by <br />feet by <br /> <br />Storage <br />Storage <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 -0-) <br /> <br />1/00 <br /> <br />For Premises Permit Renewal Applications On',y: 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 />feet for a total of <br /> <br /> <br />feet for a total of <br /> <br /> <br />feet for a total of <br /> <br /> <br />feet for a total of <br /> <br /> <br />feet for a total of <br /> <br /> <br />Combined total <br /> <br />tJCo <br /> <br />square feet. <br /> <br /> <br />square feel. <br /> <br />square feel. <br /> <br /> <br />square feet. <br /> <br /> <br />square feet. <br /> <br /> <br />square feel. <br /> <br />'/0 <br /> <br />Lawful Gambling Activity ..y>......... <br /> <br />T m.bling activity that will be conducted at this gambling premises. Check all that appl'j1/.'?' /'#1 <br />'/'-1,,-<>2- '//Olf'. i7 1. <br />11'''-'1 Paddlewheels [K] Pull-Tabs 0 Raffles ~ Tiplioards<'17' ~ <br /> <br />m of Lease Amended Lease Only <br /> <br /> <br /> <br />The term of this iease 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 />wrjtjJ in the date that the changes will be effective <br />...L-1 /'1 /0 2..,.. Both parties that signed the lease <br />must initial and date all changes. <br /> <br />eestions on this form should be directed to the Licensing <br />ction of the Gambling Control Board (Board) at 651-639- <br />4000. This publication will be made available in alternative <br />format (i.e. large print, Braille) upon request. Hearing impaired <br />individuals using a TTY 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 />