Application For Extension Of Premises Patio Permit
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Application For Extension Of Premises Patio Permit Form. This is a Arizona form and can be use in Liquor Licenses And Control Statewide.
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Tags: Application For Extension Of Premises Patio Permit, LIC 0105, Arizona Statewide, Liquor Licenses And Control
ARIZONA DEPARTMENT OF LIQUOR LICENSES & CONTROL
800 W Washington 5TH Floor
Phoenix AZ 85007-2934
(602) 542-5141
400 W Congress #521
Tucson AZ 85701-1352
(520) 628-6595
APPLICATION FOR EXTENSION OF PREMISES/PATIO PERMIT
THIS APPLICATION MUST BE RETURNED TO THE DEPARTMENT OF LIQUOR
Permanent change of area of service – Give specific purpose of change:
Temporary change for date(s) of:
1. Licensee’s Name:
Last
First
Middle
2. Mailing Address:
City
State
3. Business Name:
Zip
LICENSE #:
4. Business Address:
City
5. Business Phone: (
)
COUNTY
Residence Phone:
State
(
)
NO FAX # (
6. Do you understand Arizona Liquor Laws and Regulations?
YES
7. Have you received approved Liquor Law Training?
Zip
)
YES When?
NO
8. What security precautions will be taken to prevent liquor violations in the extended area?
9. Does this extension bring your premises within 300 feet of a church or school?
YES
NO
10. IMPORTANT: ATTACH THE REVISED FLOOR PLAN CLEARLY DEPICTING YOUR LICENSED PREMISES AND WHAT YOU
PROPOSE TO ADD.
****After completing sections 1-9, 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.
This change in premises is RECOMMENDED by the local Board of Supervisors, City Council or Designate:
(Authorized Signature)
I,
(Title)
(Agency)
(Date)
, being first duly sworn upon oath, hereby depose, swear and declare,
(Print full name)
under penalty of perjury, that I am the APPLICANT making the foregoing application. I have read this application and the contents
and all statements are true, correct and complete.
State of
X
County of
SUBSCRIBED IN MY PRESENCE AND SWORN TO before me this date
(Signature of Owner or Agent)
Day
Month
Year
My commission expires on:
(Signature of NOTARY PUBLIC)
Investigation Recommendation
Approval
Director Signature required for Disapprovals
LIC 0105 05/06
Disapproval
by:
Date:
Date:
*Disabled individuals requiring special accommodation, please call the Department(602) 542-9027.
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