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DLLC USE ONLY Job #: TEMPORARY EXTENSION OF Date Accepted: PREMISES/PATIO PERMIT CSR: Arizona Dept. of Liquor Licenses and Control 800 W. Washington St. 5" Floor Phoenix, AZ 85007 (602) 542-5141 Type or Print with Black Ink *OBTAIN APPROVAL FROM LOCAL GOVERNING BOARD BEFORE SUBMITTING TO THE DEPARTMENT OF LIQUOR* Temporary change (No Fee) for date(s) of: ///.©5/42 through // Jol / AX license#: OIA 790.200 $b ? « Specific purpose for change: Choc Lu, Eun t 1. Agent/Individual Name: Pe herson Andrew So Last First Middle 2. Premises Name (Doing Business As-DBA): Ac li aglon @rcill 3. Premises Location Address:_ [W300 3S - old Us ftw 0 Arlimbon Az SS322 4. Mailing address: 5. Email Address: 6. Business Phone Number: _@ 23-327-2i 31 Contact Phone Number: Po 7. Do you understand Arizona Liquor Laws and Regulations? Aves LINo 8. Does this extension bring your premises within 300 feet of a church or school? Dyes No 9. Have you received approved Liquor Law Training? PAves No ~ : 10. What security precautions will be taken to prevent liquor violation s in the extended area? We will have Setuci ty Ond Eenced acee all opornd For Dev one + enkr of lejve acea vuoilk nem remtaines, algo We il heave cheek FO atk all entrances. 7/21/2022 Page 1 of 2 Individuals requiring ADA accommodations please call (602)542-2999 11, IMPORTANT: Attach the revised floor plan, clearly depicting your licensed premises along with the new extended area outlined in black marker or ink, if the extended area is not outlined and marked “extension” we cannot accept the application. BARRIER oO Barrier Exemption: an exception fo the requirement of barriers surrounding a patio/outdoor serving area may be requested. Barrier exemptions are granted based on public safety, pedestrian traffic, and other factors unique to a licensed premises. List specific reasons for exemption: O Approval O _ Disapproval by DLLC: SIGNATURE Declaration: |, (Print Name) Cndrea de Ceberson , declare under penalty of perjury that | am authorized to submit this application. | have read the contents of this application, and to the best of my 7 knowledge believe all statements made on this application to “A correct and complete. ral 7 Signature GOVERNING BOARD After completion, and BEFORE submitting to the Department of Liquor, please take this application to your local Board of Supervisors, City Council or Designate for their recommendation. This recommendation is not binding on the Department of Liquor. DO Approval 0 Disapproval Authorized Signature Agency DLLC USE ONLY Investigation Recommendation: Oo Approval oO Disapproval by: Director Signature required for Disapprovals: 7/21/2022 Page 2 of 2 individuals requiring ADA accommodations please call (602)542-2999 = wo x= = < © ro) 08 SN PIO oogle po pair RE PO8. e Lypleor SE en Maxar Technologies, U.S. Geological Survey, USDA/FPAC/GEO, Map data ©2022 — — — — PN yo on.