Glendale Live Entertainment Permit Application

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Glendale Live Entertainment Permit Application Powered By Docstoc
					    ~~~n CITY OF GLENDALE, CALIFORNIA                                                            613 East Broadway, Room 110
               City Clerk                                                                      Glendale, California 91206-4393
                                                                                            (818) 548-2090 Fax (818) 241-5386
                                                                                                       www.cLglendale.ca.us


Application for Live Entertainment Permit                           Application Fee: $750.00
GMC Code Sections 5.60.010-5.60.090                                 Permit Fee: $100.00 (upon approval)
                                                                    Requirements:
First Application _ _                                                   Supplement to Application: Yes
Renewal _ _                                                             Personal Affidavits: Yes
Permit #: LlV_ _                                                        Photographs: New Applications Only ($12)
                                                                        Fingerprints: New Applications Only ($81)
Date: _ _ __ _ __ _

Business Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ __
Address: _ _ __ ----;-:--".-_ _ _ _ _ _ _ _ _ _ _ _----;-c:::7_ _ _ _ _ _ _ _ _ _ _-;:-;-c,.-_
                       (street)                                           (city)                                      (zip)
Phone: _ _ _ _ _ _ _ _ _ _ _Hours of Operation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Description of Business: _ _ _ _ _ _ __ _ _ _ __ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Ownership:           Individual        Partnership_ _       Corporation _ _
      Individual:    Name:
                     Home Address:
                     City and Zip:                                                 Phone:
       Partnershil2: Name:
                     Home Address:
                     City and Zip:                                                 Phone:
                     Name:
                     Home Address:
                     City and Zip:                                                 Phone:
       Corl2oration: Officer's Name:
                    Home Address:
                    City and Zip:                                                  Phone:
                     Officer's Name:
                    Home Address:
                    City and Zip:                                                  Phone:
                    Officer's Name:
                    Home Address:
                    City and Zip:                                                  Phone:
Manager or Person in Charge:
                     Name:
                     Home Address:
                    City and Zip:                                                  Phone:
                                            (t"nntinll~n   nn rp\lQrc::;p.\
                                                                                                                                0
                                                                                                                              WE RECYCll
Have you or any partnership or corporation of which you were a member or officer had any license or permit
denied, suspended or revoked by any state, territory or governmental agency? _ _ _ _ __ __ __ _

If you answ ered " Yes" to the preceding question, attach a supplementary statement giving a complete and
detailed explanation , including dates, names used, license or permit numbers, reasons and convictions. Any
plea of nolo contendre must be disclosed.

                          ATTACH COMPLETED SUPPLEMENTARY PA GE IF REQUIRED
•••••••• •   ••••••• •• •• •   •••••• •   •• •   ••••••• •   •• •   •••••••••••• •• •• ••••• • ••••••••••• b ••••••   ~   ••••••• 1




      I have read and understand the provisions, rules and regulations of the City of Glendale, California and
the Municipal Code governing the type of license or permit for which I am applying.

       I declare under penalty of perjury that all of the information contained in this application and any
accompanying documents is true and correct, with full knowledge that all statements made in this form are
subject to investigation. Any false or dish onest answer to any question may be grounds for denial or
subsequ ent revocation of li cense or permit.



                                                                                                (signature)



                                                                                                  (title)



                                                                                                  (date)




SUBSCRIBED AND SWORN TO BEFORE ME THIS _ _ _ _ DAY OF_ _ _ __ __ •_ _                                                     _ __




  (Notary Public or any other person authorized to
   administer oaths.)




"Notary not required on RENEWALS"
_LIVE ENTERTAINMENT

       Specific type of entertainment to be provided:


-----~------------------------------------------------ ----

----------------------------------------------------------


Attach a list detailing:

1. The two (2) addresses immediately prior to present address of
applicant(s).

 2. Business occupation or employment of applicant(s) for the three (3)
years immediately preceding the date of the application .

. 3.   The entertainment business license history of the applicant(s).
                               CITY OF GLENDALE
                                                       •
                                                      818-548-2090



                  PERSONAL AFFIDAVIT IN SUPPORT OF APPLICATION

PLEASE PRINT OR TYPE                                                 DATE: _ _ _ _ _ _ __



FULLNAME~-------~~------~~~-----
               Last                           First                      Middle

                                            HOME
RESIDENCE.~-----------=_--------~~~~PHONE~(-)~----
        Street         City       State/Zip

                                                           BUSINESS
BUSINESS _ _ _ _ _ _ _ _ _ _ _--,:-:-_ _ _ _----,:----:=-_,PHONE ( ),_ _,-
           Street              City             State/Zip

DESCRIPTION_ _ _ _ _ _ _ _ _ _ _ _ _ _ _~__---~~---
           Date of Birth Sex Hgt. Wgt. Hair Color Eye Color


DRIVER'S LICENSE NO. ____________-----'SOCIAL SECURITY_________________

List any and all other names used for legal identification:




Have you ~ been convicted of a felony and/or misdemeanor? If answer is "YES" list the dates, specify the
conviction, and identify the court and case number.



I HAVE READ AND UNDERSTAND THE PROVISIONS, RULES AND REGULATIONS OF
THE CITY OF GLENDALE, CALIFORNIA AND THE MUNICIPAL CODE GOVERNING
THE TYPE OF LICENSE OR PERMIT FOR WHICH I AM APPLYING.

                                              Organization: _______________________

                                                      Signed:_______________________

                                                       TitIe: ______________________


K-182 (Rev. 7/18/05)

				
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