103-Cupertino Senior Center Coordinating Council.pdfOFFICE OF THE CITY CLERK
CITY HALL.
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
TELEPHONE: (408) 777-3223 • FAX: (408) 777-3366
CUPERTINO
APPLICATION FOR BINGO PERMIT
1. Name of Organization OD AG 1+�
Name of Officers S
Address of Officers
2. Days of operation DDr Hours of Operation 97D nj
3. Address of Bingo game J e.' gs-61 y,
4. Purpose of premises used by organization Actildh ills 47 361 an
5. Ownership of Bingo equipment r"
6. Name of person responsible for opera ion of Bingo game A4 da CL2y'a-
7. Name of everyone who has any financial interest in Bingo gameyln[rUta�taex
PS
8. Name of contact CL /a� ' -b emyN I 1-ke irpeit go
Address of contact IMO
Phone & email of contact
Senr&a Ce>&r enaa l addreS-S avid Phone. SGniorCAtcrpertim, of `('
MUST HAVE THE FOLLOWING 409 -777 -31 SO
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.
D. Floor plan of room where gaming will take place showing the exit(s)
E. Will food or drinks be served? Y 1/ N
If yes, describe the type, how it will be served, and where it will be prepared
C AAD
Tre pckre41Yt C%> Pe rV-i no So Y) I m! GvMc e r— ttumn .
J.",
Signature of person responsible 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 OFF CIAL USE ONLY
Sheriff recommendation YES NO 'Fof COIP` IA 1e 1 (OXI 'Me
Fire District YES NO uC 7-
Health Officer YES�NO f n fi1�� l��h^
Chief Building Inspector YES NO ft`/��
Director of Planning YES�NO
Time of public hearing
Business License No. NA h • W r a � ; �
Cupertino Senior Center Coordinating Council
2010-2011 Officers and Addresses:
Ron Moore (President)
19967 Pear Tree Court
Cupertino, CA 95014
Evelyn Phoa (Vice President)
10413 Meadow Place
Cupertino, CA 95014
Melissa Yu (Recording Secretary)
10299 McKlintock Ln.
Cupertino, CA 95014
Jill Rozmiarek (Corresponding Secretary/Treasurer)
4571 Madoc Way
San Jose, CA 95130
Amanda Cuva (Bingo Committee Chairperson)
18890 Tuggle Ave.
Cupertino, CA 95014
APPLICATION FOR BINGO PERMIT
The Santa Clara County Sheriff s Department may inspect the Bingo Records of the
Cupertino Senior Center.
The premises used for the Cupertino Senior Center Bingo are owned by the City of
Cupertino.
aywTi'evlo m2v
Amanda Cava
Bingo Committee
Tax Exempt Status:
The City of Cupertino's Tax Exempt I.D. # is 94-6027368.
The Domestic Nonprofit Corporation is the Cupertino Senior Coordinating Council.
Corporation No. 0899275-CS3CC.
Linda Yelavich
From: epostcard@urban.org
Sent: Friday, October 29, 2010 3:26 PM
To: Senior Center
Subject: Form 990-N E-filing Receipt - IRS Status: Accepted
Organization: CUPERTINO SENIOR COORDINATING
EIN: 94-2853675
Submission Type: Form 990-N
Year: 2009
Submission ID: 7800582010302dz93740
e-File Postmark: 10/29/2010 6:20:30 PM
Accepted Date: 10/29/2010
The IRS has accepted the e-Postcard described above. Please save this receipt for your
records.
Thank you for filing.
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e-Postcard technical support
Phone: 866-255-0654 (toll free)
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CUPERTINO SENIOR COORDINATING
21251 Stevens Creek Blvd
Cupertino, CA 95014
1
CITY OF
CUPEkTINO
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Cupertino Senior Center
21251 Stevens Creek Boulevard
Cupertino, CA 95014-3255
(408) 777-3150
Fax. (408) 777-3156
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