88-1368 WHITE - C�TV CLERK
PINK - FINANCE COUI�CII �+
BI.UERV - MAYORTMENT GITY OF SAINT PAUL File NO. �d��3G
Council Resolution �
. _ .,
Presented By �z����%����1 -
Referred To Committee: Date
Out of Committee By Date
RESOLVED: That app1ication (ID #13946) for a State of Minnesota
Class B Gamb1ing License by Johnson Area Hockey at
959 Arcade Street (Governor's) be and the same is hereby
approved.
COUNCIL MEMBERS Requested by Department of:
Yeas Nays
Dimond
Lo� [n Favor
Goswitz ,�/
Rettman �!J
��;�� Against BY
Sonnen
Wilson .�p
AUt7 � 6 1�0� Form Approved by City ttor ey
Adopted hy Council: Date ' � �/�( /,(�
� J 7.1�
Certified Passed '1 Se ar BY
Bp
A�p by Mavor: Date ���� � 4� Approved by Mayor for Submission to Council
By By
PU�.lS��� . ,.� � 2 7 1988.
.�. �fAT�OR. . . .. ,g ` .. . . . . OAaE NMTED � . OA�IE�lEf� � . . � . -.���lY
•' :
Mr. J. Carchedi � �t���N 5��� No::�p���� :
ca�rrA4T vE�oM � o�rurn�+r oa�cron w,ra�roA��wn .
Christine Razek �� — ����� ��«�
, aou,�,o ��a� � Counci 1 Resea rch
F . :_ ; �5 0�+: �„ ,«�„�,-r«�, _.'
Applicat�on fpr a S�ate Class B Gambling License
Notificatio� Date: 7-20-88 Hearing Date: _ 8-16-8�
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mrnNO co�ow reo eaa scHOa earo
sr� cw�mEa oo►�wnse�or� co���s�s aoor:e+�a.,�oeo* nFrv ro caNS�r
. .. . - - . � . � _ . . _^ - . . - � -_FoR AODL MF�. . �._�AODED*��� � .
D�RICf COIIWCr. � � � . .. . - � . .
'R EIfR�11U1T10N: �� . . - . . .
.. BLIPPORiB YMtlCM COUNCIL aB�kCTIVE? . . . . . . . . . . � . .. � . � � . . .
M11�1�IY#AO�tilr�1�.GP�OIITtlIr1Y(YVIW.WhlL VYIle1k YV119fe.YN1�: ,
_ $ruce Wigen, on behalf of Johnson Area Hockey, requests Council approval
of his apalication for a State Class B Gan��i-ng License at 959 Arcade Stre�t
�(6overnor's). Proceeds €rom the :pulltab sa�es wi11 be asecf to support
, y ouuth hockey. _ :
���.�.o••.�r.. _ , _ :.
Council Research Center.
All fees and appli�ations have been submitted.
, , _.
, . : .
AUG 5 1988
�yan+.t wt�e�,.na r�v+�om�:. , ' . . _ . ..;..
If Council approval is given, Johnson Area Hockey wi11 begin.� pulltab
sales at Governor's. If Council approval is not given, pulltabs wi11
>. not be. sald at Gavernor's. , �
. :N.'�►n�: w� ,: cows "
. ~"'�dhnson Area is currently licensed for pulltab sales at Minnehaha Lanes, �
�5 Seminary. All paperwork and lUX pay�rients have been submitted in a. timely
� manner. This office has received no compiaints an the conduct of tMeir sales.
_ . T�he�-a�=e�-�►sp��� •• *�;z e�€T^�,���'•�—
��:
There is one other organization with 2 pulltab locatiuns in St. Paul - East �'wfns
' Babe� Ruth (one l ocati on i s not curren�tl y operati ng, twt `i t i s l i censed).
. � ��-�-�3��
, DiVISION OF LICENSE ANI) PERMIT ADMINISTRATION llATE � pZ g o �' / � � �
T , �
INTE,RDF.PARTMEATAL REVIEW C:HECKLIST A.ppn Proc ssed/Recei ed by
� Lic Enf Aud
Applicant �rU��. �V� e!"a Home Address 70 � �. L-O�QG�Q�
�—_
Rusiness Name J��h��n �hQ��Q(,�Q� Home Phone
Business Address �S-! ���o�L Type of License(s) ��� �4SS �
Business Phone ��� -9 yo p ��yy�,b f(�(,� L-1 G2 l'1S'�
Public Hearing Date �l��a �� License I.D. �F �J� `� �p
at 9:00 a.m, in the Council Chambers, n/
3rd floor City Hall and Courthouse State Tax I.D. 4t ���7
llate Notice Sen � Dealer 4f 1V
to Applicant � ��
Pederal I'3rearms 4� ��"
Public Nearing
DATE I1�SPECTIUN
REVIEW VERFIED (COMPUTER) CUMMENTS
A roved Not A roved
�
Bldg I & D �
�IIq'
Health Divn. �
, � Q� !
� �
� i �
Fire Dept. �
i ��� I
� f
Police Dept.
� �� �S �.
�
License D�ivn. '
aK � � ao �
City Attorney � �
� c� C�
Date Received:
Site Plan � 2� �
To Council P.esearch �
Lease or Letter / � Date
from Landlord �� � �
a� _ --
� ..`...� `1.c�._...-��:_� - �:
" ��,M ' , _ �, City of Saint PaW. '� t��
Department of Finance and Management Senrices ���
��� ' �-- �• License-a�d Permit�Divisiort- r�,
203 City Hall- ' �/Q i����
St. Paul, Minnesota.55102=29&505��
. , APPLlCAT'f�N FOR LLCENSE
, CASH CHECK CLASS NO. New• Renew
� /� i 1 \/ � i . -- .
` Oate � � � �� 19 `� �
i
Code Noc Tttle of license � ; � � '� ;� � '.'i�
F�om � 19'�To 19_�
�3 3 �� �;, � � �,. ;�,.-�. ;=p� �.�:� �� ; ; �
r 1
100 Ir"1 !ir� �:)1�; 1 � �:'�„ .�-�- ` r(��� .,�
AppllcanUCompany Name
100 -
` C"
�-• ' �1� /
100 euslness Name „�., _ _
t 00. Y( .� /� "� �� L�i�1 � ; , : ) 1�`.
8usinsss Addross. Phon�Na.
.--.
100 �' ' ; ,
, � , �
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100 Mail to Address. Pnom Na
T .
lOQ � ,
ManaperlOw�sr-Nims° ,
100 • -
r � `� :_. �`�' -+ �
100 AlanageNGwner•Hom�Addresa. • Phon�No.
4pg8 Applicatfon Fee- 2 Sa �.- — �
.Rxelved the�Sum of i00 �. ? . �, � ; `�� '- �
_ i . , , ': �_. � 'l�(-,
J �� ManageNOwner•Gty,State 3 Zip Cadc
t00 Total 100
���CY//��J�� "/r 1 '�!'; �1!�L''?'1
Ucense Inspecior ��-/ gy; ���� SignaWre of AppliqrM :
Bond•
Comparry Name� Poliep Na. Expi�tlort Oate°
,` r� i ._ _ ' _ _ _ � `. _ /- ` ,! ' _�_ .
Insurance: ''` — , - _ . _, ... �✓ . % ,
Company Name- PoNey Na Expiration Oate
MinnesotaState Identification No. ' �� � � � Social Security No.
Vehicle information:
Serial Number ats Number
Other
THIS IS A RECEIPTFOR APPLICATTON
THIS IS NOT A UCENSE TO OPERATE Your application for license wili either be granted or rejected subject to the provisions of the zoni�g
ordinance a�d eompletfort of the inspections by the Health, Fire.Zoning andlor ticense Inspectoro»
$I5.00 CHARGE FflR ALL RETURNED� CHECKS
1
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__ .. .. __ _ ----- - �"" _-- ---- - ----- - --- - - _
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� ._� _ ` , Cicy o: Sainc Paul C�f�('p��
�} t t--. --=-. p,epatcment aE F,inanc�aad.Management S��vices �:-�--- � �r=:-- :
'fi;,,: :
�� , .. � �Divtsiorr o� Liceas� aa� Pe�it Registratiocr
\,. . �� . r . _.'�}�, yC+," �--":n'!t" '. . ,�., t.:. � �`. .. , _.. . � , . . , . � - .. .'.�; � .. � ��
INE�RMATION REQUIREIZ WIT� APPLICATION FOR PERMIT TO CDNDUCT CAARLTABLE' GAMBLING GAME IN
�.°'SAINT� PAUL. _ , �r E ..� t..�...:+�.._-� a z_.�::�;_. �.� ...,. _�:,.�" '-�. �.'' .�...�.�-��w�..._..� ,�� �:_�- ..._.
3�� ., ... . . . . . .._ .-. t .. .
1.. Fu1L and; crnaglet�.namea o�;; organizatiom �hic�.is,a�app�lying; fot License. �v�V�;�o(�'
� .
, '� l�•Y'�Cti.. 1"�a.�� ..�560G..- � �- �_ . . ,-, f , ,
: , ._. �.
+ 2. Add=ess> where: games: �ill be: he�ld_ q 5 1 ��1/���..- �►�la \ '" �� �d�
._.. ._... ___._.�._.__..�.,__ ,.___.., __.._._..__.�,�..�_-�.
Yumbe� Street___ City Zip
.... ��
.. ,.�:_ ___..._
3:� ' Na�e: of'Ymaaager signing- this� appTication�� wha wf.11 conduct,� operate:. and manage-
;-- `, ; ., _ - .... . . . _ .
� , , , , .. _ :_ . ,.. _ ...:. .
. , _ .: . ,. ..
_� _ GamhLing. Games-° f'-(�,- (,d>�� Date: o£-F Birth- �� �� � �
'. , _.. - • r,. :
_.._ _ _ --�---._. _.. _ ...
_.� _ �
_ -_
(a) Le.ngth of time� manager has. beeA memher oi. app�licanc.:a.rgaaizacieri �p � �0.✓'�_
, , ,. , • ,
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4. Address,. of: Manager �p� . ___. _,_.___..� �_�„G\U 2_ s'�•f"'c�.v�.t µ ^_.FJ' JIvL
: _._ .
Yumber , , �, Screec � ��� � _ . �'fti'. _. ;. ,. , . Zip.
_ __.
_.�.� . � i
5. Day��dates,. and. hou=s: this applicat.ion_ is.,cor � G`.Q T � q, (�v��� �
6. � Ls:the applicant ar organfzatfo� o=gaafze�..under ch�: laws of t:�� State-ef �t? � Q.�
7. Da.te of: incotperation- 1 /� _ . ,; , : - �, � t � ,`�-�.�
_.. - -�---_ __ _ _
8... ffat�whe�:�egtstered:.witY� th� S�tat�oP:itaaescra� �I13 ; � _� `, '° "� . -
., ,
� 9.- FIo� ]:nII �ha�; o aaizat�ans bee�i.��exfstenc�?= _.���''y �C.�Ir"5 '� '. ... _ _�w
� -.��.- ...�.--...�. .n��... .. �.. � �.. _... S .. . ..Ti
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10.:>�-Ho� 1Dn� ha� orgaaizacio� tree�i�esisteace ia: S C�-PauZ?`�f.��/;Q.r'� �`S ', ._::, ,_� N
..
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_. . . .. _._ ... : _ . .. .,.:r$_. a. _...�...�._. ',::=�,,. . '°.: . . �. '.,..:.. , . , � ..
L1.,. Wtiac. is� thc gu�P'os� a� th�s orgaa�zatin�r�"="���T o`1/'''�"" V•o i..�-�-- �' . �
. _ , . _ �
v.. . ,_ � ..,_ ,. - , ..
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- �,:- _ - .
IZ. Officers o� applicant organizaCiocr -
. .__.Name �`O .�. .. _ ,�...:...��.Y�_. /� ►l -�•-j"""'jO���.l/�"
l I-
Addres�: � ��1 �� ��)i S-. lU . : .:
. ` _ ,q_f'p ...Addtess:. �,,�V'"1,-•` '
Title �rP.�.i�_��- DOB 1 a- � ^ Title:�EL�t/�.`'�✓�` DOB �I� ��
_ . _ . �� _
Na�� L 1 Q 1n ���O��O✓" Yamc �.T�� �Gt✓''.�'r'`�
�- t���.."", ._........_._.,:.._......_. : �-_._, : � .__ .!..:•i..�.::___n ,
..._.�._._...._ L, �r ,__•dr
__._ _ _:. _. 5 �l N T . . . � � �� �:�� �:-�- .
Address. � °�--V �ddzess L Vpj'Tj/
L , ,_ _�_ ._,;-_ ...7�ro b �
. _-Title,..�_ _ .....��.. _. _...DOB'. �. .�.�. a�---�--- Titlz- II�QliS�t'-� DOB_ `
.. . . _ _ .:_.__�_.__..�__,_. . .
_ _,._ _. .._._. .
�.� _. � L � .._...___
13_ Give names of officers, or any ot:�er pe�sorrs ano paid cor� se^rices to ctte organ�_ation.
Name Vame
-• . ._ __.._.__.._. .. _ _
�� Address _ ?,ddress
,
Title ?'��le.
(Attach separace saee�� '.^.r aca===or.s�. ::a=as. '.
. _ : ` - ' . ' � . _
�
14. Actached hereco isa.a- Lis� oF-nam�sA act� ad�dresses. o£ aIL` �em�ers oE the organi2� �r�,. �,
. ._. . ._. ., . , .t .,. . . , _ .. r
� �. :--�--''.: __. .. � .__ :��. . . ___ f •
. r.
15. Ic� whose- custody� wi11 organization:`s:: record� b� keper '�'
. ., . _
:__ _::' � .. _� . . - ` .....: ,_._�=_:. ..::: . .__._ .__-�._ .�. '.__:.. � ' ..
. ;Y , .� 4 ,� .'�.
Name � r/" 1Q� O�y� Addres.s: L�
_ ���L�� ' �T��
_..16.��_> P.er.sons=..who w.iT1`- bt ronduccing•,:=assistin�- in��conducting-,- orr operatfngx chr gaccrs-•
` :... ,
ir'ame C t�, t^Y � !a V`�-.'�) , _� �_. �Date:r�o�B�rtEi�t c�3 �O
�,'� • � � , ,� - _ . -
.Addres�s. : ,'L��S G.—�—v1CJ� �.-�: 1`.�-
. . ., . .. .
__.. _ _._ � °
._.. _ . ... ,.
Name. o� S ouse `�'� ---�--
P DacQ of Birth
,, „ _
_ , , ..
. ; . . ._. . _ . 1/�,°'}
Dates. vhen such person will conduct,. assisL, or- operace• Vd�y�l o�S l
�
� � w�� � - �Q.. ��%'�, ,_ : '
� `" Namei_V_oG� � 1����-� K�.. . .... Date: of Bi_th 'rJl°� � �b�
� ; ,
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�. -._ .. . . _. ._ _ _ _.
9ddress ._��1�(� � �.�<S Cw_ t�V1 •' 41
.�—� �____�_
; Nam� of' Spouse:; . Date o� Bizth
� �
:' � Dates--when. such� persctt� *.ri?1 caaducr,.. asg_st,. o� aperate _�C��(`►c�(,�S (/�� ��-
��/'1 v� �� W-2�2� _
17". Have� you: read aa+cf da po�. choraughlyx unde::sta�r� ch� provfsioa� aE au, law�,: or�inances,
and regulatior.s- g..�aer�a� :.h�, operat=o�:.n=;: Cha��tahiea Ga�iszu�.���s?::.. ��
..._�_____._ ,..._._._....._..�_._..--_____�---- _.. .___._:__ �
18. Attached: hare=a- on: c:�e��fcr��°ur�tshed bv}-the.:C:.tp�a::r Sc..� Pairl._i��� FiaaaciaL' Repozt'
"'�whic:�. icemizes-TaL��'.recei�cs, e.�enses,....ars� disbu�sements o�: che. apglicaac organizaci.on:
� as we?l,as ai:., orgaa:za�'_eng Waa, iia.va�:ecai.�re�,`uad� zer c:�ev er.ece�z� caLenda� year
__ _.. . . .._ _.:.._. ... �,.:__. �_ . . .._.,..�_._.
which ;�as� beeZ:�s:3�ed;�,. pre�ared, aa�d:,ve�_:e�:-�,y � �... - .. � . � , ;
._
, , . ,
_ ._�.��._..__..._.,...�_.r�._.�.. a.�_..__ __..�._._._..._.r _:_..:.. _�,.-�:..�._._._.._ �
. .. _ �iame
, � - -� . : �ddress , ; __.
. .
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.� �... .v.__ _ __ _ _,. .__.__J_..____...� .__��...,._ _,_ < ,' � .�. . _. � _
Wha: is they �� --�:. ' ' � o.�. cEce anpli''caat� Orgaaizacinn.
._..___._ ,._ . .__. . Yame_ or� OfP:ce- . __ , , _
- , ,
. ... . ;
. :. . _ , .. . � ,_, ;
,•° , :�.� . • .. ; . . :- �
;__ � ___ _. . __. - -
19:-�' Operacor of premises��vhere�.games :riL' �e- heLd:
•; ,
-►- , t/ ._..T. , ;� ! �j
�. � � `
�.'vr� ' , , r _,. _
.__ .__Nam�. ,r.. 1SryL�N=h`�SC '_ _ _ ._----.� _, __ _ „_.._ .___ : , :. :..,
,
; . � ; � . _ �.__._.. . ._ ___._. _,.__ ' _. ..
� Bcrsf:ae ss'Add r�s� ��G{ G✓`�"n d�
�J � i �= � -. - �
-� Honre- Address �j � �"�y.
--.. ; �_.r.?- t
20. �►mount of renc paid by applicsat Orgaai�a.cion ror reZC oi: che hall; specify amount
paid ger 4-hou� seas:on '�----'� _ . _- --
"3 . ' ��'_/,�(��
.f t._ .y:-,..�.�_.�.. . -. � . .
�, ��' 'L� � . . ., � ' . .
f
��,. 21.. fhe- pzcceeds oc the: games: wi11 be-� dishursed_ after- deduc[in�, prize layout costs and
op�erating expenses for the £olTowfng- purpose� an� uses�.
� � � .� � eS �d�`� �-�-�n� Q�S b►� Q.V�e:� t t a�-�c�
�r,,,� � .` ; .
22� Has. the: premises where th� games ar� to� he- he-ld been: cer.tified for occupancy by the
City oE Saiac Pau1? V -�`j
23. Has your. orgaaization ciled cederaL forn� 990 T?" � If_ answer is: yes, please_ atcach
a capy wic:� this appiicacion�. Ic answar is ao� plain� why:.
Any changes desireci �v- tne a�ol=canc �ssociac_on_ may be- �ade only wi.ch. the. consent: of the
City Council. �
����.,� �rco� ��c�-�
Organizacion_
Date� !_Q I 2��k I �'Y BY:.
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� :..�o;�0��4� Charitable Gambling Control Board FOR BOARD USE ONLY
'��'�• Room N-475 Griggs-Midway Building
- �3 1821 University Avenue �°°N�1°`
; _ St. Paul, Minnesota 5 5 1 04-3383 AMT
(612) 642-0555
rt''1 { � CHECK#
DATE
GAMBLING LICENSE APPLICATION
� INSTRUCTIONS:
A. Type or print in ink.
B. Take completed application to local governing body,obtain signature and date on all copies,and leave 1 copy.Appiicant keeps 1
copy and sends original to the above address with a check.
C. Incomplete applications will be retumed.
T�pe of Application:
. ''�Glass A — Fee S 100.00(Bingo,Raffles,Paddlewheels,7ipboards, Pull-tabsl
�Ctass B — Fee S 50.00(Raffles,Paddtewheels,Tipboards, Pull-tabsl �ed�spay�sco:
❑C1ass C — Fee 5 50.00(Bingo only) M�"°"°te a'°^tabl°Ge'"blk'g c°"crd Board
' OClass D — Fee$ 25.00 IRaffles only)
DYes CNo 1. Is this application for a renewal? If yes,give complete license number � - 0 - ��
❑Yes�No 2. If this is not an application for a renewal,has or anization been licensed by the Board before? If yes,give base
ticense number(middle five digits) ` '�`~f�
" �]Yes❑No 3. Have Internal Controls been submitted previously?If no,piease attach copy.
4. Applicant(Official,legal name of organization) 5. Business Address of Organization
�
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6. Citw State,Zip ` 7. County 8. Business Phone Number
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9. Type of organization: �Fraternal ❑Veterans ❑Religious .�lOther nonprofit*'
"If organization is an"other no�profk"organization,answer questions 10 through 13.If not,go to quesiion 14."Other nonprofiY'organizations
must document its tax-exempt status.
'�Yes❑No 10. Is organization incorporated as a nonprofit organization?If yes,give number assigned to Articles or page and
book number. � � Attach copy of certificate. _� -i ° � -�.
�JYes❑No 1 1. Are articles filed with the Secretary of State?
�JYes�No 12. Are articles filed with the County?
�Yes ONo 13. Is organization exempt from Minnesota or Federal income tax?If yes,please aitach letter from IRS or Department of
�. Revenue declaring exemption or copy of 990 or 990T.
'` ❑Yes1�7No 14. Has license ever been denied,suspended or revokedl if yes,check ail that a ly:
CDenied ❑Suspended ❑Revoked Givedate: -
` �-°- 15. Number of active members 16. Number of years in existence Note: If less than four years,attach
; " .� evidence of three years
� . _� �� E ' � existence.
- 17. Name of Chief Executive Officer 18. Name of treasurer or person who accounts for other revenues
` of the organization.
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` Title Title f �
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� Business Phone Number Business Phone Number '`
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19. Name of establishment where gambling will be 20. Street address(not P.O.Box Numberl
conducted � �
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21. City,Stste.ZiP 22. County Iwhe�e gambling premises is Iocated)
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CG-0001-02(8/86) White Copy-Board Canary-Applicant � Pink-Local Governing Body
. � . . . , � �--�Y-�.�1 I'
Gambling License Application Page 2
Type of Application: ❑Class A OCtass B ❑Class C ❑Class D
�Yes�No --.23. Is gambling premises located within city limits?
,LJYes�No 24. Are ait gambling activities conducted at the premises listed in �19 of this application? If not, complete a separate
application for each premises(except rafflesl as a separate license is required for each premises.
❑Yes�No 25. Does organization own the gambling premises?If no,attach copy of the lease with terms of at least one year.
❑Yes No 26. Does the organization lease the entire premises7 If no,attach a sketch of 27. Amount of Monthl Rent
the premises indicating what portion is being leased.A lease and sketch g. . ! �-
is not required for Class D applications. �.vA�t►�C o✓� n��+-u
❑Yes�No 28. Do you plan on conducting bingo with this license?If yes,give days and times of bingo occasions:
Days Times
,�lYes�No 29. Has the S 10,000 fidelity bond required by Minnesota Statutes 349.20 been obtained?Attach copy of bond.
30�Insurance Company Name ^ 31. Bond Number
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32. Lessor Name . ' 33. Adliress 34. City,State,Zip
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35. Gambling Manager Name 36. Address 37. City,State,Zip
'�f— � . , . c- `1'i • `
38. Gambling Manager Business Phone 39. Date gambling manager becam�
( :�! 1 ► -,�;,� - � c�-7 �'` member of organization: i p j-��
GAMBLING SITE AUTHORIZATIQN.
By my signature below,local law enforcement officers or agents of the Soard are hereby authorized to enter upon the site,
at any time, gambling is being conducted,to observe the gambling and to enforce the law for any unauthorized game or
practice.
BANK RECORDS AUTHORIZATION
By my signature below,the Board is hereby authorized to inspect the bank records of the General Gambling Bank Account
whenever necessary to fulfill requirements of current gambling rules and law.
OATH
1 hereby declare that:
1. I have read this application and all information submitted to the Board;
2. All information submitted is true,accurate and complete;
3. All other required information has been fully disclosed
4. I am the chief executive officer of the organization;
5. I assume full responsibility for the fair and lawful operation of all activities to be conducted;
6. I will familiarize myself with the laws of the State of Minnesota respecting gambling and rules of the Board and agree,
if licensed,to abide b those laws and rules, includin amendments thereto.
40. Official,Legal Name of Organization 41. Signature�must.be signed by Chief�ecutive Officer)
.. ir.i.\tif`I? . . . ."f . .1 .\ ��(J X F� .��F •�� ;�f '�.,+f
� Title of Signer ' Date �
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ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY
I hereby acknowledge receipt of a copy of this application. By acknowledging receipt, I admit having been served with
notice that this application will be reviewed by the Charitable Gambling Control Board and if approved by the board, will
become effective 30 days from the date of receipt(noted belowl,unless a resolution of the local governing body is passed
which specifically disallows such activity and a copy of that resolution is received by the Charitable Gambling Control
Board within 30 da s of the below noted date.
42. Name of City or County(Local Governing Body1 If site is located within a township,item 43 must be completed,in
_. addition to the county signature.
_ 4 " ` - .-�
Signature of person receiving application 43. Name of Township
X ,___ /
Title Date received 130 day period Signature of person receiving application
begins from this date)
X
44:',Name of Person delivering application to Local Goveming Body Title
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CG-0001-02 (8/86�, �` White Copy-Board Canary-Applicant Pink-Local Governing Body
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