No preview available
HomeMy WebLinkAboutApplication for Zoning Compliance - Use Permit OFFICE USE ONLY: DATE FILED: ��4-1 C�0�3 PERMIT#: Cost: $55.00 PLANNING&DEVELOPMENT SERVICES BUILDING&CODE REGULATIONS DIVISION 2300 Virginia Avenue Ft. Pierce, FL 34982-5652 _.. 772-462-1553 Fax 772-462-1578 APPLICATION FOR TEMPORARY USE PERMIT BUSINESS NAME: {� Gam. l_(�GG� 4 D✓� `�J-1 NAME OF EVENT: ��liv (od--) �1 Gln t G LOCATION AND ADDRESS OF TEMP RY USE EVENT: PROPERTY TAX IDENTIFICATION#: -330q —SQ/ " 00-5-2 i 0®0' _ DESCRIPTION OF TEMPORARY USE: 6 ie 1 1 F U-P✓!� PC A f L DATES OF THE EVENT: I , 1 q y 1 Li C) lfJ APPLICANT'S NAME: I C,��Q- el,\ APPLICA'NT'S ST ET ADDRESS: vl O61 G- QK E �� G 1�C CITY: et . 1_e(_6 6 STATE: )r-cl ZIP CODE:�� WILL THE EVENT HAVE A TEMPORARY LIQUOR LICENSE:YES Y NO WILL THE EVENT HAVE A TENT(s):YES NO X (up to 900 square feet exempt from fire permit) WILL THE HAVE BANNERS/PENNANTS/FLAGS?YES /NO-9—(Only 1 per 300 linear feet;32 sq ft max size) I HEREBY ACKNOWLEDGE THAT THE ABOVE INFORMATION IS CORRECT AND AGREE TO CONFORM TO ST.LUCIEE COUNTY LAND DEVELOPMENT CODE,SECTIO .02. J. PRINT APPLICANT'S NAME SIGNATURE OF APPLICANT STATE OF FLORIDA,COUNTY OF S/4mir LuCNs ACKNOWLEDGED BEFORE ME THIS /Z DAY OF RiCIL -,20 //0 , BY &�e r Afien WHO IS PERSONALLY KNOWN TO ME ZC, OR WHO HAS PRODUCED �/ / AS IDENTIFICATION. %ym Lh ma� 1�e-lllr7 er- aSIGNATURE OF NOTARY TYPE OR PRINT NAME OF NOTARY u TITLE: NOTARY PUBLIC COMMISSION NUMBER: FF 97a SLCPDS 10/19/2015 4 Notary PubIIC State of Fbtida Kevin G Mueller My Commission FF 979410 a�d�' Expires 06/17/2020 PERMISSION FROM OWNER OF PROPERTY DATE: AS OWNER OF THE FOLLOWING DESCRIBED PROPERTY,I AUTHORIZE-JA f It' LO rd UA/0 or, C� �if/C. TO HOLD A TEMPORARY USE EVENT. PROPERTY TAX IDENTIFICATION#: 3� LEGAL DESCRIPTION OF PROPERTY:- _ OTA Lk 36 -il) Lo 7' 1 ✓`� � yI ^/'P S s jes /2 Ae- yr 3,-ID� PROPERTY ADDRESS: OWNER INFORMATION: .1 �✓ PROPERTY OWNER'S NAME: �' /. L i,�c3C ���, ".�j)t, ��� �l(,,J/%��S h L�r a Ly PROPERTY OWNER'S ADDRESS: 2 5 ` 47 ES ✓1'1 3 D i��y �} CITY: s�-'� Z' L STATE: ZIP CODE: �J z- 1�� 7A::7 r�J PRINT OWNER'S NAME SIG TURE Oi0WXfi STATE OF FLORIDA,COUNTY OF 514wT LuCI4E ACKNOWLEDGED BEFORE ME THIS l Z DAY OF f-//JiQ/L ,20_/o,( , BY / �'TB1' /�//�!7 WHO IS PERSONALLY KNOWN TO MEX OR WHO HAS PRODUCED AS IDENTIFICATION. &t//;7 C.-Alue-Ilefo- SIGNATURE OF NOTARY TYPE OR PRINT NAME OF NOTARY TITLE: NOTARY PUBLIC COMMISSION NUMBER: F/C 7 Q78V14 seal 4p00 Notary Public State of Florida Kevin G Mueller My Commission FF 978410 mor n Wires 08/17/2020 SLCPDS 10/19/2015 DBPR ABT-6003-Division of Alcoholic Beverages and Tobacco Application for One/Two/Three Day Permit or Special Sales License STATE OF FLORIDA DBPR Form DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ABT-6003 Revised 08/2013 If you have any questions or need assistance in completing this application,please contact the Division of Alcoholic Beverages&Tobacco's(AB&T)local district office. Please submit your completed application to your local district office at least(7)days prior to the first date of the event to insure the permit is issued by the event date. This application may be submitted by mail, or it can be dropped off. A District Office Address and Contact Information Sheet can be found on AB&T's page of the DBPR web site at the link provided below. http://www.mvfloridalicense.com/dbpr/abt/district offices/licensinc.htmi k � ; „SECTION 1r° CHECK TRANSACTION REQUESTED% - -= Transaction Type: Onefl-wofThree Day Permit ❑ Special Sales License ry SECTION4 PERMIT orALICENSE INFORMATION k v {- If the applicant is a corporation or other legal entity, enter the name and the document number as registered with the Florida Department of State Division of Corporations on the line below. FEIN Number Business Telephone Number E-Mail Address(Optional) 51 - (� ICi -1 ITT) 1?-)'� V v3(o Full Name of Applicant(s): (This is the name the permit or license will be issued in Department of State Document# '- - L o ` on �G Business Name(D/B/A)or Name of Event Location of Event(Street and Number) /®2 C) M r cJ cvA f' eej City ��^^ (� County ) State Zip Code t—t- [" 1�f-t.� �� t u i FL 1 34 9 9 5 Mailing Address(Street or P.O. Box) . City - StateZip Code ©(+ G.-r Luc � L _3H q U Contact Person -This section is optional,see application instructions for details Contact Person Telephone Number P -� t1-n a � 03D ext. Email Address(Optional) Pt:�+ez <1 i � rn � : t�0 Irv\ Mailing Address(Street or P.O. Box) City 1-e re, � �a(te Zip Cod � S a Date(s) Permit Desired _T �F-- �-i ��' ABT District Office Received Date Stamp Auth: 61A-5.0013,FAC 1 SECTION 3 SALES,TAX �� .� _ ._.:` >>�- _ <. TO BE COMPLETED:BYTHE�DEPARTMENT OF_REVENUE, _� � k Full Name of Applicant Organization The named applicant for a license/permit has complied with the Florida Statutes concerning registration for Sales and Use Tax and has agreed to pay any applicable taxes due. Signed Date Title Department of Revenue Stamp: x u' SN 4 ZONING ECTIOr x+ TOtBE,COMPLETD BYTHE,ZONING:AUTIORITYGOVERNINGTHE EVENT LOCATION,,, Location of Event(Street and Number) City ' County The location complies with zoning requirements for the temporary sale of alcoholic beverages pursuant to this application O /Two/Three Day Permit. Signed I ate Titlen��G Note: College fraternities and sororities must meet certain additional conditions which can be found in the application instructions and requirements. Auth: 61A-5.0013,FAC 2 x SECTION 5 DESCRIPTION OFPREMISESTO BE LICENSED Business Name(D/B/A)or Name of Event PI-C FiZ Lvc4L U n Ga--1 V\ c:, Neatly draw a floor plan of the premises in ink,including sidewalks and other outside areas which are contiguous to the premises, walls,doors,counters,sales areas,storage areas,restrooms,bar locations and any other specific areas which are part of the premises where the event will be held. A multi-story building where the entire building is to be licensed must show the details of each floor. J N L Q, p� �W �r� Auth: 61A-5.0013,FAC 3 SECTION 6 AFFIDAVIT OF APPLICANT k FOR NON PROFIT CIVIC ORGANIZATION ALCOHOLIC BEVERAGE PERMIT y `' Full Name of Applicant Or anization "This is to certify that the applicant requesting the permit in the above and foregoing application is a non-profit civic organization and that the permit, if used, will be used only by the organization making application, on the date(s) requested and at the location stated. By acceptance of this permit,we agree that the applicant organization, as the permit holder, is the ONLY entity that will receive any of the profits from the sale of alcoholic beverages on this permit. This is to further certify that the applicant organization has not received more than three(3)permits within the calendar year, unless otherwise authorized by law, and acknowledge that the location may be inspected and searched during the time that the permit is issued and business is being conducted without a search warrant by authorized agents or employees of the Division of Alcoholic Beverages and Tobacco, the Sheriff, his Deputies, and Police Officers for purposes of determining compliance with the alcoholic beverage laws. I, the undersigned individual, hereby swear or affirm that I am an officer or authorized representative and am duly authorized to make the above and foregoing statements on behalf of the applicant organization. Furthermore, I swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45, and 837.06, Florida Statutes, that theforegoinginformation is true to the best of my knowledge." STATE OF COUNTY OF -_ L IACl �//� ueller gg%V wt Notary Public State of Florida t- A , d0,VW t Expires Kevin G sion FF 978410 APP ANT/ UTHORIZED REP SENTATIVE NAME APPLICANT/AUTHORIZED REPRESENTATIVE SIGNATURE The foregoing was( )Swom to and Subscribed before me this /?-4'k Day Of A f , 20_& , By f al f' �11en who is(�personally known to me (print name(s) of person making statement) OR( )who produced I as identification. WA� I 9 Commission Expires: 6 17 Zd Z O Notary Public Auth: 61A-5.0013,FAC 4 u SECTION 7 'AFFIDAVIT;OF APPLICANT ; s �3 Y3 - FOR SPECIAL SALES GCENSE y� t n ^ Full Name of Applicant Organization "I,the undersigned individual, or if a corporation, its authorized representative, hereby swear or affirm that I am duly authorized to make the above and foregoing application for a special sales license which authorizes the sale of alcoholic beverages for period of up to three(3)days. I understand this license does not permit the sale of alcoholic beverages for consumption on the premises and only allows package sales in sealed containers and.acknowledge that the location may be inspected and searched during the hours that the special sale is being conducted without a search warrant by authorized agents or employees of the Division of Alcoholic Beverages and Tobacco, the Sheriff, his Deputies, and Police Officers for purposes of determining compliance with the beverages laws. swear under oath or affirmation under penalty of perjury as provided for in Sections 559.791, 562.45, and 837.06, that the foregoing information is true to the best of my knowledge and that no other person or entity except as indicated herein has an interest in the special sales license and that all of the above listed persons or entities meet the qualifications necessary to hold this special sales license." STATE OF COUNTY OF APPLICANT/AUTHORIZED REPRESENTATIVE NAME APPLICANT/AUTHORIZED REPRESENTATIVE SIGNATURE The foregoing was( )Sworn to and Subscribed before me this Day Of , 20 . By who is( )personally known tome (print name(s) of person making statement) OR( )who produced as identification. Commission Expires: Notary Public Auth: 61A-5.0013,FAC 5 ATTESTATION This form is to be completed by the alcoholic beverage license holder ONLY when the event of the non profit organization is being held at a location that is licensed,by the Division of Alcoholic Beverages&Tobacco for the sale of alcoholic beverages. Note: This attestation must have the original signature of the alcoholic beverage license holder(only persons on file with the division may sign) and must be submitted by the non-profit group along with the application for the One/Two/Three Day Permit. Licensee: Business Name(DBA): License#: Series of Permanent License: Type: Contact Person Telephone Number ext. E-Mail Address(Optional) Name of Non-Profit Group: Date(s)of Event IMPORTANT A One/Two/Three Day permit is being requested for an event to be held on your licensed premises. During the event, no sales or service of alcoholic beverages may be made under your alcoholic beverage license in the area identified for use by the non-profit organization. Failure to comply will result in administrative charges being filed against your license. Signature of Licensee: Date: Auth: 61 A-5.0013,FAC 6