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102-Application for Alcoholic Beverage License.pdfDepartment of Alcoholic Beverage Control State of California APPLICATION FOR ALCOHOLIC BEVERAGE LICENSES) ABC 211 (6/99) TO: Department of Alcoholic Beverage Control File Number: 505662 100 PASEO DE SAN ANTONIO Receipt Number: 2028056 ROOM 119 Geographical Code: 4303 SAN JOSE, CA 95113 Copies Mailed Date: November 4, 2010 (408) 277-1200 Issued Date: DISTRICT SERVING LOCATION: SAN JOSE First Owner: PAIZ 2 INC Name of Business: rb6HT WINC-t-F000 Location of Business: 20333 STEVENS CREEK BLVD CUPERTINO, CA 95014-2225 County: SANTA CLARA Is Premise inside city limits? Yes Census Tract 5081.01 Mailing Address: (If different from premises address) Type of license(s): 41 Transferor's license/name: Dropping Partner: Yes No License Type Transaction Type Fee Type Master Dup Date Fee 41 - On -Sale Beer And Wine ANNUAL FEE NA Y 0 11/04/10 $350.00 41 - On -Sale Beer And Wine ORIGINAL FEES NA Y 0 11/04/10 $300.00 Total $650.00 Have you ever been convicted of a felony? No Have you ever violated any provisions of the Alcoholic Beverage Control Act, or regulations of the Department pertaining to the Act? No Explain any "Yes" answer to the above questions on an attachment which shall be deemed part of this application. Applicant agrees (a) that any manager employed in an on -sale licensed premises will have all the qualifications of a licensee, and (b) that he will not violate or cause or permit to be violated any of the provisions of the Alcoholic Beverage Control Act. STATE OF CALIFORNIA County of SANTA CLARA Date: November 4, 2010 Under penalty of perjury, each person whose signature appears below, certifies and says: (1) He is an applicant, or one of the applicants, or an executive officer of the applicant corporation, named in the foregoing application, duly authorized to make this application on its behalf; (2) that he has read the foregoing and knows the contents thereof and that each of the above statements therein made are true; (3) that no person other than the applicant or applicants has any direct or indirect interest in the applicant or applicant's business to be conducted under the license(s) for which this application is made; (4) that the transfer application or proposed transfer is not made to satisfy the payment of a loan or to fulfill an agreement entered into more than ninety (90) days preceding the day on which the transfer application is filed with the Department or to gain or establish a preference to or for any creditor or transferor or to defraud or injure any creditor of transferor; (5) that the transfer application may be withdrawn by either the applicant or the licensee with no resulting liability to the Department. Applicant Name(s) Applicant Signature(s) .PAIZ 2 INC See 211 Signature Page State of California APPLICATION SIGNATURE SHEET ("SIGN N") Department of Alcoholic Beverage Control • This form is to be used as the signature page for applications not signed in the District Office. ❑Sole Owner Partnership -Ltd • Read instructions on reverse before completing. Partnership Corporation • All signatures must be notarized in accordance Married Couple RLimited Liability Company with laws of the State where signed. Domestic Partner DOther 41 ®Original Person to Person Transfer Exchange Premise to Premise Transfer 1-1 Other P*2- ?-, /lye- 6. APPLICANT'S MAILING ADDRESS (Street address/P.O. box, city, state, zip code) a®333 SIFee^4^ 61ycel< 11lvd , C�gs dy 7. PREMISES ADDRESS (Street address, city, zip code) AO 3 3 3 S fie,.-75 Crrel< r3lc��, Cu m- . C� id v is APPLICANT'S CERTIFICATION Under penalty of perjury, each person whose signature appears below, certifies and says: (1) He/She is an applicant, or one of the applicants, or an executive officer of the applicant corporation, named in the foregoing application, duly authorized to make this application on its behalf; (2) that he/she has read the foregoing and knows the contents thereof and that each of the above statements therein made are true; (3) that no person other than the applicant or applicants has any direct or indirect interest in the applicant or applicant's business to be conducted under the license(s) for which this application is made; (4) that the transfer payment of a loan or to fulfill an agreement entered into more than ninety (90) days preceding the day on which the transfer application is filed with the Department, (b) to gain or establish a preference to or for any creditor or transferor, or (c ) to defraud or injure any creditor or transferor; (5) that the transfer application may be withdrawn by either the applicant or the licensee with no resulting liability to the Department. I understand that if I fail to qualify for the license or withdraw this application there will be a service charge of one-fourth of the license fee paid, up to $100. PARTNERSHIP/LIMITED PARTNERSHIP (Signatures of general partners only) KI M CORPORATION 10, PRINTED NAME (Last, first, middle) SIGNATURE Ivan Mozara X TITLE *President Vice President Chairman of the Board PRINTED NAME (Last, first, middle) SIGNA Frank Ashton X 9/ Secretary �Asst. Secretary Chief Financial Officer nAsst. Treasurer LIMITED LIABILITY COMPANY l�l�Q�vls� /r/�e//o 11, The limited liability company is member -run 11 Yes DNo (If no, complete Item #12 below) 12. NAME OF DESIGNATED MANAGER, MANAGING MEMBER OR DESIGNATED OFFICER (Last, first, middle) first, r illV110 ABC-211-SIG (2/09) "SIGN ON"