Department of Alcoholic Beverage Control STATEMENT RE: RESIDENCES (Rule 61.4) State of California Governor Applicant: Please complete left side of form, then sign. List addresses of all residences within 100 feet of your proposed premises. If there are none, write 223None.224 Measure all distances by direct line from the closest edge of the residential structure to the closest edge of your structure or parking lot, whichever is closer. Your 223parking lot224 includes any area that is maintained for the benefit of your patrons or operated in conjunction with your premises. Continue on reverse if needed. 1.APPLICANT NAME 2.PREMISES ADDRESS (Street number and name, city, zip code) 3.RESIDENCES WITHIN 100222DEPARTMENT USE ONLY LTR PERS DATE DISTANCE SEPARATION FACTORS 1. ft. NAME LTR PERS DATE DISTANCE SEPARATION FACTORS 2. ft. NAME LTR PERS DATE DISTANCE SEPARATION FACTORS 3. ft. NAME LTR PERS DATE DISTANCE SEPARATION FACTORS 4. ft. NAME LTR PERS DATE DISTANCE SEPARATION FACTORS 5. ft. NAME LTR PERS DATE DISTANCE SEPARATION FACTORS 6. ft. NAME LTR PERS DATE DISTANCE SEPARATION FACTORS 7. ft. NAME LTR PERS DATE DISTANCE SEPARATION FACTORS 8. ft. NAME NON-INTERFERENCE (For Department Use Only) I acknowledge that any false, misleading or omitted information required in this statement may constitute grounds for denial of application for the license, or if the license is issued in reliance upon information in this statement which is offered, false or misleading, then such misinformation or omission will constitute grounds for revocation of the license so issued. 4.APPLICANT SIGNATURE DATE SIGNED ABC-247 (rev. 0/1) American LegalNet, Inc. www.FormsWorkFlow.com INFORMATION AND INSTRUCTIONS Rule 61.4, Chapter 1, Title 4, California Code of Regulations states: No original issuance of a retail license or premises-to-premises transfer of a retail license shall be approved for premises at which either of the following conditions exist: (a)The premises are located within 100 feet of a residence.(b)The parking lot or parking area which is maintained for the benefit ofpatrons of the premises, or operated in conjunction with the premises, is located within 100 feet of a residence. Where the parking lot is maintained for the benefit of patrons of multiple businesses in the vicinity of the premises, the parking area considered for the purpose of this rule shall be determined by the area necessary to comply with the off-street parking requirements as mandated by the local ordinance, or if there are no local requirements for off-street parking, then the area which would reasonably be necessary to accommodate the anticipated parking needs of the premises, taking into consideration the type business and operation contemplated. Distances provided for in this rule shall be measured by airline from the closest edge of any residential structure to the closest edge of the premises or the closest edge of the parking lot or parking area, as defined herein above, whichever distance is shorter. This rule does not apply where the premises have been licensed and operated with the same type license within 90 days of the application. Notwithstanding the provisions of this rule, the department may issue an original retail license or transfer a retail license premises-to-premises where the applicant establishes the operation of the business would not interfere with the quiet enjoyment of the property by residents. A residence is defined as a place where people actually live, such as a single family home, condo, residential hotel or motel, or mobile home. A determination must be made as to whether or not your proposed premises is located in an area as described above. In order to make such determination, it will be necessary for you to complete the front of this form, to be submitted at the time you file a formal application. If you can establish that your business will not disturb the residents, your license may be issued subject to appropriate conditions. American LegalNet, Inc. www.FormsWorkFlow.com