102-St Joseph Cupertino Church application.pdfOFFICE OF THE CITY CLERK
CITY HALL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
TELEPHONE: (408) 777-3223 • FAX: (408) 777-335E
CUPERTINO
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APPLICATION FOR BINGO PERMIT
Name of Organization
Name of Officers
Address of Officers
Days of operation Mfg . -,A- Sp�Tr Hours of Operation 4' 00 12LDD PH
Address of Bingo game _Af1C) DC 5Z)/�%
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Purpose of premises used by organization
Ownership of Bingo equipments}faP0
Name of person responsible for operation of Bingo game l�
Name of everyone who has any financial interest in Bingo game
S. Name of contact l `u°(Vi`1'l ` (3 __
Address of contact o
Phone & email of contact 41OK-1,1_2311-C2789 Ze f i`
MUST HAVE THE FOLLOWING
A. Consent for Sheriff to inspect bank account containing Bingo profits.
B. Statement of ownership/lease of premises.
C. Copies of exempt status from Internal Revenue and Franchise Tax Board
or tax identification number. T4-27`3`1503
D. Floor plan of room where gaming will take place showing the exit(s)
E. Will food or drinks be served? Y V N
If yes, describe the type, how it will be served, and where it will be prepared
cj) S e-R- i i ea. -V.r j-0k ;j
Signature of person csponsible for Bingo game
FEE: $50.00 - General License annual. Over 10 games.
5.00 - General License each game. Under 10 games.
THIS PERMIT IS NONTRANSFERABLE EITHER AS TO THE LICENSE OR LOCATION
FOR OFFICIAL USE ONLY
Sheriff recommendation
YES_y/ NO
fat` e-"-$. Caldefor�t
Fire District
YES NO
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Health Officer
YES NO
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Chief Building Inspector
YES NO
NO
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Director of Planning
YES
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Time of public hearings
Business License No. A m-
Statement Of Ownership/Lease Of Premises
St. Joseph of Cupertino
10110 N. DeAnza Blvd.
Cupertino, CA 95014
December 3, 2010
The Santa Clara County Sheriffs Department may inspect the Bingo records of St. Joseph
of Cupertino. The premises used for St. Joseph of Cupertino Bingo are owned by the
Church/Diocese of San Jose.
"C
Ed Ramage
Chairman, St. Joseph Bingo
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