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?>/ - a% C0 Ply Do not detaCh_.._,Urn all copies Do Not Wri�f Above This Line—for Headquarters office only APPLICATION FOR ALCOHOLIC BEVERAGE LICENSES) 1. TYPE(S) OF LICENSE(S) FILE NO. To: Department of Alcoholic Beverage Control RECEIPT NO. 1901 Broadway ,. Sacramento, Calif. 95818 5- ` J`` `tet~r GEOGRAPHICAL (DISTRICT SERVING LOCATION) CODE - The undersigned hereby applies for Date licenses described as follows: Issued Temp. Permit 2. NAME(S) OF APPLICANT(S) Applied under Sec. 24044 ' Effective Date: Effective Date: 3. TYPE(S) OF TRANSACTION(S) FEE LIC. TYPE 4. Name of Business 5. location of Business—Number and Street JAN 11 1W ,7 ti. :;•� f ,.. ..��_ � let_ City and Zip Code County $ TOTAL 4.1.;U 6. If Premises Licensed, 7. Are Premises Inside Show Type of License "' City Limits? 8. Mailing Address (if different from 5)—Number and Street (Temp)(Perm) 9. Have you ever been convicted of a felony? 10. Have you ever violated any of the provisions of the Alcoholic Beverage Control Act or regulations of the Department per- taining to the Act? 11. Explain a "YES" answer to items 9 or 10 on an attachment which shall be deemed part of this application. 12. Applicant agrees (a) that any manager employed in on-sale licensed premises will have all the qualifications of a licensee, and (b) that he will not violate or cause or permit to be violated any of the provisions of the Alcoholic Beverage Control Act. 13. STATE OF CALIFORNIA County 'of--__-_____' _1__ 1'--� += -------------Date----------------- ---------- Under penalty of perjury, each person whose signature appears below, ce rtifes and says: (1) He is the applicant, or one of the applicants, or an executi• officer of the applicant corporation, named in the foregoing application, duly authorized to make this aoplication on its behalf; (2) that he has read the fora going application and knows the contents thereof and that each and all of the statements therein made are true; (3) that no person other than the applicant or applicants has any direct or indirect interest in the applicant's or applicantsbusiness to be conducted under the licensees) for which this application is made; (4) that the transfer application or proposed transfer is not made to satisfy the payment of a loon or to fulfill an agreement entered into more than ninety ,901 days preceding the day on which the transfer application is fled with the Department or to gain or establish a preference to or for on;, creditor of transferor or to defraud or injure any creditor of transferor; (5) that the transfer application may be withdrawn by either the applicant or the licensee with no resulting liability to the Department. 14. APPLICANT SIGNHERE .------------------------------------------r --------------------------------------------------------- ---------------------------------------------------- -------------------------------------------------------------- APPLICATION BY TRANSFEROR 15. STATE OF CALIFORNIA County of______________________________________Date-________--------_-________-. Under penalty of perjury, each person whose signature appears below, certifies and says: (1) He is the licensee, or an executive officer of the corporate licensee, named in the foregoing transfer application, duly authorized to make this transfer application on its behalf; (2) that he hereby makes application to surrender all interest in the attached licenses) described below and to transfer some to the applicant and or location indicated on the upper portion of this application form, if such transfer approved by the Director; (3) that the transfer application or proposed transfer is not mod, to satisfy the payment of a loan or to fulfill an agreement entered into more than ninety days preceding the day on ..,hi,h the Iran,(,, application ,s F.led with he Department or to gainar . to bli.h a preference to or for any creditor of transferor or to defraud or injure any creditor of transferor; (4) that the transfer application may be withdrawn by either the applicant or the licensee with no resulting liability to the Department. 16. Name(s) of Licensee(s) 17. Signature(s) of Licensee(s) 18. License Number(s)