Applicant Name:

Address:

Home Phone:

Name of Business:

Town of Livermore

Special Amusement Permit Application

Business Phone:

Business Address:

Town of Livermore Tax Map:

Lot:

Nature of Business:

Property Owner's Name (if different from applicant):

Address:

Name(s) and Home Address(es) of all Managers, Partners or Corporate Officers:

Has the Applicant or any Manager, Partner or Corporate Officer ever been convicted of a felony?

Yes:

No:

(Please attach a separate sheet describing, specifically, each conviction)

Has the Applicant ever had a business license denied or revoked?

Yes:

No:

(Please attach a separate sheet describing, specifically, each revocation)

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Please indicate distance, in feet, to the closest part of each of the following:

Church, synagogue or other house of religious worship

Public or private elementary or secondary school

Day care facility

Public park or recreational facility

Any other premises holding a Special Amusement Permit

Any residence on adjacent property (excepting that of the owner or proprietor of the premises subject to this application).

Specific forms of Entertainment to be covered by Permit (see Section 103.1 of Town of Livermore Special Amusement Ordinance:

Please note if any proposed form(s) of entertainment were regularly conducted prior to June 10, 2010, the date(s) each commenced, and at what intervals each was conducted (daily, weekly, monthly, etc.).

By signing below, the applicant authorizes the Town of Livermore's Code Enforcement Officer or any other duly authorized representative to enter upon the licensed premises to verify the information contained within this application and as otherwise specified in Section 205 of the Town of Livermore Special Amusement Ordinance.

Signature of Applicant

Date:

An application shall not be considered complete if it fails to contain any of the information requested herein, any of the additional documentation specified in Section 207 of the Town of Livermore Special Amusement Ordinance, or the required application fee.

Date Accepted by Town Clerk:

Town Clerk's Signature:

Fee Paid:

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