DR 8447 (05/01/08) COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION 1375 SHERMAN STREET DENVER, COLORADO 80261 (303) 205-2300 Applicant is a: Corporation Individual BED AND BREAKFAST PERMIT APPLICATION Partnership Limited Liability Company 1. Name of Applicant State Sales Tax Number 2. Trade Name of Establishment (DBA) 3. Address Phone Number City County State ZIP Code 4. Mailing Address (Number and Street) City or Town State ZIP Code • Attach a copy of a deed or lease in the exact name of the applicant only, reflecting possession of the permitted area for at least the minimum duration of this permit (1 year from date of issuance). • Attach a diagram of the premises which accurately reflects the area where alcohol beverages will be stored, served, possessed or consumed. Pursuant to 12-47-410, C.R.S., Applicant hereby states that it qualifies for a Bed and Breakfast Permit, in order to serve complimentary alcohol beverages, and certifies to the State Licensing Authority: ________________ That it has no more than 20 sleeping rooms, and ________________ That it provides at least 1 meal per day at no charge other than for overnight lodging, and ________________ That it does not sell alcohol beverages by the drink or in sealed containers, and ________________ That it will not serve alcohol beverages for more than 4 hours in any one day, as follows: Monday Hours Tuesday Hours Wednesday Hours Thursday Hours Friday Hours Saturday Hours Sunday Hours From: m. From: m. From: m. From: m. From: m. From: m. From: m. To: m. To: m. To: m. To: m. To: m. To: m. To: m. OATH OF APPLICANT I declare under penalty of perjury in the second degree that I have read the foregoing application and all attachments thereto, and that all information therein is true, correct, and complete to the best of my knowledge. Signature Title Date REPORT AND APPROVAL OF LOCAL LICENSING AUTHORITY (CITY/COUNTY) The foregoing application has been examined and the premises, business conducted and character of the applicant is satisfactory, and we do report that such permit, if granted, will comply with the applicable provisions of Title 12, Articles 46 and 47, C.R.S., as amended. THEREFORE, THIS APPLICATION IS APPROVED. Local Licensing Authority (City or County) Date filed With Local Authority Signature Title Date REPORT OF STATE LICENSING AUTHORITY The foregoing has been examined and complies with the filing requirements of Title 12, Article 47, C.R.S., as amended. Signature Title Date DO NOT WRITE IN THIS SPACE - FOR DEPARTMENT OF REVENUE USE ONLY DATE LICENSE ISSUED $50.00 2340-100 (999) LICENSE ACCOUNT NUMBER $0.00 2102 750 (999) PERIOD TOTAL American LegalNet, Inc. www.FormsWorkflow.com