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CSR: Amount: SPECIAL EVENT LICENSE app Duc use only APPLICATION FEE $25.00 PER DAY Date Accepted: Arizona Dept. of Liquor Licenses and Control CSR: 800 W. Washington St. 5" Floor Phoenix, AZ 85007 (602) 542-5141 Type or Print with Black Ink 1-10 days consecutive days only, Cash, Checks or Money Orders Only SECTION 1 Applicant must be a member of a qualifying nonprofit organization, political party, or Government entity and authorized by an Officer, Director, or Chairperson of the Organization. 1. Applicant: Jeremy Lee Perry 2. Applicant's mailing addres City State Tip 3. Applicants home/cell — _ Applicant's business phone: 6027024933 4. Applicant's email crcvoss SECTION 2 Name of Non-Profit Organization, Candidate or Political Party/Gov.: 16x16 Inc SECTION 3 Non-Profit/IRS Tax Exempt Number: 84-3185007 SECTION 4 Arizona Corporation Commission File #: 23021197 If out of State please specify: SECTION 5 Event Location Name: McDowell Mountain Regional Park SECTION 6 Event Address: 16300 McDowell Mountain Drive, Fort McDowell, Arizona 85264 (Four Peaks lot) SECTION 7 Dates and Hours of Event. Days must be consecutive but may not exceed 10 consecutive days. **SEPARATE APPLICATION FOR EACH “NON-CONSECUTIVE” DAY** Event Start License End Time AM/PM Time AM/PM DAY 1: 11/3/2022 Thursday 5pm 10 pm DAY 2: 11/4/2022 Friday 10 am 10 pm DAY 3: 11/5/2022 Saturday 10 am 6pm Days Date Day of Week DAY 4: DAY 5: DAY 6: DAY 7: DAY 8: DAY 9: DAY10: 7/21/2022 Page 1 of 3 Individuals requiring ADA accommodations please call (602)542-2999 SECTION 6 What type of security and control measures will you take fo prevent violations of liquor laws at this event? (List type and number of police/security personnel and type of fencing or control barriers, if applicable.) Number of Police Number of Security Personnel [Fencing Warrers E .__. Participants wishing to purchase alcohol will have IDs checked prior to sale. ‘xplanation: Cones and signage stating ‘no alcohol outside this area’ (or similar language) will be placed at the entrance and exit of the Ragnar Village SECTION 7 Will this event be held on a currently licensed premises and within the already approved premises? LlyesWINo If yes, Local Governing Body signature is not required. Name of Business License Number Phone (Include Area Code) SECTION 8 How is this special event going to conduct all dispensing, serving, and selling of spirituous liquors? Please read R-19-318 for explanation and check one of the following boxes. [place license in non-use Lbispense and serve alll spirituous liquors under retailer’s license Wbispense and serve alll spirituous liquors under special event Cspiit premise between special event and retail location SECTION 2 What is the purpose of this event? Vion-site consumption Doottsite (auction/wine/distilled spirits pull) Lboth SECTION 10 1, Has the applicant been convicted of a felony, or had a liquor license revoked within the last five (5) years? LlYesINo If yes, attach explanation. 2. How many special event days have been issued to this organization during the calendar year? 3. Is the Organization using the services of a Licensed Contractor? LyesWINo If yes, please provide the Name of the Licensed Contractor: 4. |s the organization using the services of a series 6, 7, 11, or 12 licensee to manage the sale or service of alcohol? LlYes[VINo if yes, please provide the Name of Licensee: License #: 5. List the name of the Individual or Organization that will receive revenues, MUST EQUAL 100%, 0, Name: 16x16 Inc Percentage: 100% _PO Box 30111 Phoenix AZ 85046 Address: Street City State Tip Name: Percentage: Address: Street City State Zip 7/21/2022 Page 2 of 3 Individuals requiring ADA accommodations please call (602)542-2999 Please read A.R.S. § 4-203.02 Special event license; rules and R19-1-205 Requirements for a Special Event License. ALL ALCOHOLIC BEVERAGE SALES MUST BE FOR CONSUMPTION AT THE EVENT SITE ONLY. SECTION 11 License premises diagram. The licensed premises for your special event is the area in which you are authorized to sell, dispense or serve alcoholic beverages under the provisions of your license. Please attach a diagram of your special event licensed premises. Please show dimensions, serving areas, fencing, barricades, or other control measures and security position. H DIAGRAM If the special event will be held at a location without a permanent liquor license or if the event will be on any portion of a location that is not covered by the existing liquor license, this application must be approved by the local government before submission to the Department of Liquor Licenses and Control. Please contact the local governing board for additional application requirements and submission deadlines. Additional licensing fees may also be required before approval may be granted. For more information, please contact your local jurisdiction. Declaration: |, (Print Name) Jeremy Perry , 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 knowledge believe all statements made on this application to be true, correct and complete. sig natufe Date Received: L, recommend LIAPPROVAL [1 DISAPPROVAL (Government Official) (Title) On behalf of (City, Town, County) Signature DIAPPROVAL CI] DISAPPROVAL BY: A.R.S. § 41-1030. Invalidity of rules not made according to this chapter; prohibited agency action; prohibited acts by state employees: enforcement; notice B. An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a licensing requirement or condition unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement or condition. D. This section may be enforced in a private civil action and relief may be awarded against the state. The court may award reasonable attorney fees, damages and all fees associated with the license application to a party that prevails in an action against the state for a violation of this section. E. A state employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or dismissal pursuant to the agency's adopted personnel policy. F. This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02. 7/21/2022 Page 3 of 3 Individuals requiring ADA accommodations please call (602)542-2999 897S8 ZV ‘aleps}109s Aq 42d UlEJUNO! ||BPMOQII| OOEST 0] syed INO — eg |eUOIZay UIeJUNO|\ ||aMOGII| ywnoAe] asejiA Cuoziy [les seusey (qe zt) sajes 9g Suljdwes daaq juedioiwed uoljauu02 Jaye ® suol9auu0d J3]eM *B JaMod ® wajioraiqeuog AA “ease SIY} ApIsyno joyooje ou Suljesipul (saul| pe}y0p pau) ase\jiA seusey ay} 0} S20Ue1]UB OM} 4} Je paoe|d aq ||IM a8euSis pue sauod