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i r <br />NAME ESTABLISHMENT WHERE GAMBLING WILL BE CONDUCTED <br />of oi1 <br />2555 Sni011ilmg Ave N <br />Rosevi11s S'15113 <br />el I PIE L}'T I WITHIN THE CITE` LIMITS?: Y <br />COUNTY LESSOR I'NP' ION <br />DOES yOTjR ORGANIZATION' OWN THIS S ITR : NO <br />IF NO, LIST, THE LESSOR: <br />Nazareth Bldg aisioc <br />2555 N Snialling Ave <br />Ro eV111 O mX S 5 x.13 <br />OF PROPERTY' 'OWNER (WHEN NOT LESSOR) -W <br />SQUARE FEET PER MOB <br />r4 �.1%lrlr7L 91919 'Amwvrr nwol 1. ]Y r 5; T0X : 7'2 18 <br />AMOUNT PAID FOR RENT PER MONTH 'a %f <br />AMOUNT PAID PER 1 <br />Rosevi .1O comm Sank & Norwee <br />15011 N' Cl,o R C-1220 N Col Rd Z <br />Roseville, a Arden Ni MX 5!1131 <br />GAM,LING, 2000602 - 355152 <br />WITHDRAWALS ON nM L11C )VIDED BELOW LIST THE NAME, ADDRESS AND TITLE OF AT LEAST TWO PERSONS <br />Y <br />7; •�I r <br />r GAMBLING <br />I 0hn, <br />R TO COKPLETE THE REVERSE RSR SIDE OF THIS APPLICATION) <br />THIS FORM WILL BIE MADE AVAILABLE <br />N ALTERNATIVE FORMAT' (I.E. PRINT, BRAILLE) UPON REQUEST <br />