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� �y <br />D�CC <br />Q H <br />��� <br />�M� <br />tn <br />��o <br />HC <br />F+ <br />Q�A <br />rH� <br />� <br />M <br />w <br />�� <br />� <br />� <br />I `� <br />I �� • <br />L _ <br />� <br />TFIE APF'LICANT IS REf,iUIRW TO Pf20VIDE CERTIFICATION Cft HAVE APPLICATION <br />NOTARIZED. <br />Certificatinnt-'�� <br />I, �!1M S a�S �� �O_ �'1Z+ certify under penalty of perjury <br />_(Tn"I <br />of the laws of the State of Washington that the forgoing statements and <br />those attachmen�s hereto are true and correct. <br />DATED tliis �g_jh___��Y' of_�U _, 19�. <br />— �licant s n ir7 � <br />OR: <br />Notar : <br />Ppplicant's 5 gnature <br />State of Washington) <br />ss. <br />County of �1�pli,��y) <br />I certify trat(''�I kno or h ve satisfactory evidence�name of applicant) <br />that .�y,m�4`::_j�_ `��li�� <br />signed this applicat�on and acknowledged t to be his/her free and <br />voluntary act for the uses and purposes of applying for a City of Everett <br />Public Dancehall License. Dated: ' � 'G -� <br />Signaturn nf Notary Public: ��_.�/ ----- <br />Title: L`� <br />My appointm�nt Expires: L-� 5' Clj_. ----- <br />(Seal or Stamp in Space Above) <br />Approve------Reject <br />Police:,, <br />Fire: <br />Pl anning :_,. <br />Duilding:__ <br />Taxes: _ <br />Licenses: <br />Fee: <br />Date Paid: s� i ��,?= <br />Receipt II: ' l� (r�`i <br />Date Issued: __ <br />ey: _ <br />Expiration: <br />