Glendale Arcade Devices-Arcade Establishment Permit Application by PermitDocsPrivate

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									                                        818-937-8300
   APPLICATION FOR ARCADE DEVICES AND/OR ARCADE ESTABLISHMENT
                           TITLE 5.20.070


Application Fee:              $100.00
Annual License Fee:
(Establishment)               $175.00
Annual License Fee:
(Per Device)                   $50.00
Personal Affidavit Required

BUSINESS:

NAME OF BUSINESS                                                   PHONE
ADDRESS                                      CITY                  ST./ZIP

OWNERSHIP:               INDIVIDUAL            PARTNERSHIP    CORPORATION

NAME                                         TITLE                 PHONE
ADDRESS                                      CITY                  ST./ZIP
NAME                                         TITLE                 PHONE
ADDRESS                                      CITY                  ST./ZIP
NAME                                         TITLE                 PHONE
ADDRESS                                      CITY                  ST./ZIP

STATEMENT SETTING FORTH THE MANNER AND METHOD OF PROVIDING ADULT
SUPERVISION AT THE BUSINESS LOCATION (MANAGER/PERSON IN CHARGE /MUST BE AT
LEAST 21 YEARS OF AGE):

NAME                                         TITLE                 PHONE
ADDRESS                                      CITY                  ST./ZIP

NUMBER OF ARCADE DEVICES TO BE PLACED AT ABOVE BUSINESS LOCATION:__________
FIVE OR MORE DEVICES – CONDITIONAL USE PERMIT NO. _______________________________

DISTRIBUTOR OR SUPPLIER OF ARCADE DEVICES:

NAME                                                               PHONE
ADDRESS                                      CITY                  ST./ZIP

STATEMENT SETTING FORTH THE NUMBER OF OFF-STREET PARKING SPACES AND
STORAGE FACILITIES FOR AUTOMOBILES, BICYCLES, SKATEBOARDS AND OTHER MODES
OF TRANSPORTATION:
                                                    818-937-8300




STATEMENT SETTING FORTH ANY ARRESTS OR CONVICTION (MISDEMEANOR OR
FELONY) OF OWNERS, PARTNERS OR CORPORATE OFFICERS WITHIN THE PAST TEN (10)
YEARS:




HAVE YOU AS APPLICANT OR ANYONE HAVING A BENEFICIAL INTEREST IN THIS PERMIT,
DIRECTLY OR INDIRECTLY, HAD A PERMIT FOR THE SAME OR SIMILAR BUSINESS
LICENSE SUSPENDED, REVOKED OR DENIED? YES___ NO___ IF YES, PLEASE EXPLAIN:
CIRCUMSTANCES:




THE APPLICATION HEREBY APPLIES FOR AN ARCADE DEVICE LICENSE AS STATED
ABOVE, AND DEFINED IN SECTION 5.20.010 THROUGH 5.20.100 OF THE GLENDALE
MUNICIPAL CODE, OR ANY AMENDMENT THEROF, IN THE CITY OF GLENDALE, AND
AGREES TO ABIDE BY ALL ORDINANCES AFFECTING SUCH LICENSE NOW IN FORCE OR
ANY AMENDMENT THEREOF, AND CERTIFIES THAT THE FOREGOING INFORMATION IS
TRUE AND CORRECT UNDER PENALTY OF PERJURY.

SIGNED_______________________
TITLE________________________
DATE_________________________

SUSCRIBED AND SWORN TO BEFORE ME THIS________DAY_________,___________


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

NOTE: This application will be reviewed by the Police Building Inspector, Fire and Zoning Departments
and the City Clerk who reserve the right to grant same at their own discretion as to whether the
applicant is a responsible person, firm or corporation.

This application must be accompanied with a personal affidavit from each owner, partner or corporate
officer listed on the application.

Should the license holder fail to file an application for renewal at least thirty (30) days prior to the expiration
date, or operate an arcade establishment or a location with arcade devices without obtaining a license therefore,
the City Clerk shall collect a late fee of one hundred dollars ($120.00) per month for each arcade device for
which a license has not been obtained, per GMC Sec.5.20.040(f).

								
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