Art Gallery Permit Application {DR 8443}

DR 8443 (10/01/08) coLorADo DepArtment of revenue LiquoR enFoRCemenT DiviSion 1375 SheRmAn STReeT DenveR, CoLoRADo 80261 (303) 205-2300 aRt galleRy permit AppLicAtion $71.25 neW State Sales Tax number of Applicant 2341 Art GALLery permit 1. Applicant name (i.e. ABC Gallery inc.) 2. Trade name of establishment (DBA) 3. Address City 4. mailing Address (number and Street) reneWAL Phone number County City or Town State State ZiP Code ZiP Code · Attachacopyofadeedorleaseintheexactnameoftheapplyingentityonly,reflectingpossessionofthepermittedareaforatleasttheminimum duration of this permit (1 year from date of issuance). · Attachadiagramofthepremiseswhichaccuratelyreflectstheareawherealcoholbeverageswillbestored,served,possessedorconsumed. Pursuantto12-47-422,C.R.S.,ApplicantherebystatesthatitqualifiesforanArtGalleryPermit,inordertoservecomplimentaryalcoholbeverages, andcertifiestotheStateLicensingAuthorityandLocalLicensingAuthority: ________________ That it does not sell alcohol beverages by the drink. ________________ That it will not serve alcohol beverages for more than 4 hours in any one day, no more than 15 days per year as follows: Date: From: To: Date: From: To: Date: From: To: Date: From: To: Date: From: To: Date: From: To: Date: From: To: Date: From: To: Date: From: To: Date: From: To: Date: From: To: Date: From: To: Date: From: To: Date: From: To: Date: From: To: oath of applicant I declare under penalty of perjury in the second degree that I have read the foregoing application and all attachments thereto, and that all information therein is true, correct, and complete to the best of my knowledge. Signature Title Date RepoRt and appRoval of local licensing authoRity (city/county) The foregoing application has been examined and the premises, business conducted and character of the applicant is satisfactory, and we do report that such permit, if granted, will comply with the applicable provisions of Title 12, Articles 46 and 47, C.R.S., as amended. theRefoRe, this application is appRoved. Local Licensing Authority (City or County) Signature Title Date filed With Local Authority Date RepoRt of state licensing authoRity TheforegoinghasbeenexaminedandcomplieswiththefilingrequirementsofTitle12,Article47,C.R.S.,asamended. Signature Title Date Do not Write in this spAce - for DepArtment of revenue use onLy County City Liability information industry Type License Account number Liability Date FRom Cash Fund 2341-100 (999) City 2180-100 (999) County 2190-100 (999) License issued Through (expiration Date) To total American LegalNet, Inc. www.FormsWorkFlow.com