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' The applicant is required to provide certificalfon or have this application <br /> notarized. <br /> CERTIFICATION <br /> / <br /> ,, _�} L-�p��p{-v�'��y�certify under penalty of perjury o( the laws of the <br /> State of Washington tliat the oregeing stalements and those aitachments hereto are <br /> true and correct. <br /> DATED this��day of kQ S� . 200� <br /> % <br /> / '�— _� <br /> plicant's ' ure <br /> Or <br /> NOTARY , <br /> —� <br /> A p icanl's Si ature <br /> State ot VVashin�ton ) <br /> ) ss. <br /> County of ) <br /> I certiiy that I know or have satisfactory evidence that �f(Tur~ D Q501�] (name <br /> oi applica �stip8 applicalion and acknowledged it to be hislher (ee and volunlary <br /> act for � ur ses of applying for a City of Everelt Public Dancehall License. <br /> �\5a� /,SFS ( <br /> o� N��Y Dated: _ b '��'U g <br /> P�B���oS ure o( Notary Public: � <br /> �.17�z�� y � <br /> ,�T��OF W Pc,�` <br /> Title: <br /> �__ � — �7—��U <br /> Appointment expires: _ <br /> (seal or stamp in space above) <br /> Approved Rejecled ����`: q I3 <br /> Police Fee �� � ���-a 002 321 7000 801 <br /> Fire Cash Bond: 002 239 1004 000 <br /> Planning _ Receipt # <br /> [3uilding _____ _ __ Issue Date: <br /> � <br />