10. ABC LicensesCity Hall
i 0300 Torre Avenue
Cupertino, CA 95014
(408) 777-3212
Pax: (408) 777-3366
OFFICE OF THE CITY MANAGER
SUA~IMARY
AGENDA ITEM NUMBER /b Q--
SUBJECT AND ISSUE
Application for Alcoholic Beverage License.
BACKGROUND
1. Name of Business:
Location:
Type of Business:
Type of License:
Reason for Application:
RECOMMENDATION
AGENDA DATE MavaD 2008
Hoang A. Cuong (Green Valley Liquor)
10073 Saich Way
Liquor Store
Off-Sale General (21}
Person-to-Person & Annual Fee
There are no use permit restrictions or zoning restrictions that would prohibit this use and staff
has no objection to the issuance of the license.
Prepared by:
Y
c
Colin Jun enio er
G:planning/misc/abcgreenvalleyliquor
Submitted by:
David W. Knapp, City Manager
10a-1
Printed on Recycled Paper
Department of Alcoholic Beverage Control State of California
APPLICATION FOR ALCOHOLIC BEVERAGE LICENSE(S)
ABC 2l1 (G/99)
TO: Department of Alcoholic Beverage Control File Number: 465716
100 Paseo de San Antonio Receipt Number: 1658348
Rm. 119 Geographical Code: 4303
San Jose, CA 95113 Copies Mailed Date: April 4, 2008
(408)277-1200 Issued Date:
DISTRICT SERVING LOCATION: SAN .LOSE
First Owner: HOANG CUONG A
Namt: of Business: GREEN VALLEY LIQUOR
Location of Business: 10073 SAICH WAY
CUPERTINO, CA 95014-2124
County: SANTA CLARA
Is pl-emise inside city limits? Yes C ensus Tract 5078.06
Mailing Address:
(If different from
premises address}
.Type of license(s): Zl
Transferor's license/name: 457697 / PEREZ ROBERTO Dropping Partner: Yes No
License Tyke Transaction Tkpe Fee Typg ster ~uR Date
21 OFF-SALE GENERAL PERSON TO PERSON TRANSP NA Y 0 0 4 / 04/ 0 8 $1,274.00
21 OFF-SALE GENERAL ANNUAL FEE NA Y 0 04/04/08 $507.00
21 OFF-SALE GENERAL FEDERAL PINGERPRINTS NA N 1 0 4/ 0 4/ 0 8 $24.00
21 OFF-SALE GENERAL STATE FINGERPRINTS NA N 1 0 4 / 0 4 / 0 8 $ 39.00
Total $1,844.00
Have you ever been convicted of a felony? N o
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 quesiiotts on an attachment which shall be deemed part of this application.
Applicant agrees {a) that any manager employed in an on-sale licensed premise will have alI 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: April 4, 2008
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 euch of the above statements therein made are true; (3) dial 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 witltdmtw by either the applicant or the licensee with no resulting liability to the Department.
Applicant Name(s) Applicant Signature(s)
HOANG CUONG A SnP ~l 1 ,Signature Page
10a-2
State of California Department of Alcoholic Beverage Control
APPLICATION SIGNATURE SHEET ("SIGN ON")
• This form is to be used as the signature page for 1. OWNERSHIP TYPE (Ctierdc arre)
applications not signed in the District Office. 0/ Sole Owner ^ Corporation
• Read lnstrucflons on reverse before completing. ^ Partnership ^ Limited Liability Company
• All signatures must be notarized in accordance with ^ Husband & Wife ^ Other
laws of the State where signed ^ Partnership-Ltd
2, FILE NUMBER (if any) 3. LICENSE TYPE 4. TRANSACTION TYPE
^ Original ~ Person to Person Transfer
z 1 ^ Exchange ^ Premise to Premise Transfer
^ Other
5, APPLICANT(S) NAME (Lest, flrsl, middle)
Huang, Cuong Anh
6. APPLICANT'S MAILING ADDRESS (Slreel addressrP.O. box, oily, slate, zip code)
100 Branham Ln E Apt 3114, San Jose, CA 95111
7. PREMISES ADDRESS (Street address, cMy, zip code)
10073 Saicli Way, Cupertino, CA 95014
APPLICANT'S CERTIFICATION
Under penalty of perjury, acli pperson whose signature appears
below, certifies and says: (i) He/Slie is an applicant, or one of
the
licants
or an ex
ti
ffi
f th
li
t payment of a loan or to fulfill an agreement entered into more than
ninety (90) days precedingg the day on which the transfer
li
ti
fil
d
ith th
D
t
t
b
i
bli
,
ecu
ve o
can
app
cer o
e app
corporation, named in the foregoing ap lication, duly authorized
to make this application on its behalf; ~) that he/she lies read app
ca
on is
e
w
e
epar
men
, (
) W a
n or esta
sh a
preference to or for any creditor or transferor, or ~c) to defraud or
tiilure arty, creditor or transferor; (5) that the transfer application
the foregoing and knows the contents thereof and that each Df the may be withdrawn by either the applicant or the licensee with no
above statements therein made are true; (3) that no person other
than the appplicant or appplicants has any direct or indirect interest
in the a ticant or applicant's business to be conducted under the resulting liability to the Department,
I understand that if 1 fail to qualifyy for the license or withdraw this
application there wilt be a service charge ofone-fourth of the
]icense~s~ for which this application is made; (4 that the transfer
application or proposed transfer is not made to ~a) satisfy the license fee paid, up to $100.
SOLE OWNER ,
8. PRINTED NAME (Last, first, middle) SIGNATU
Huang, Cuong Anh X ,,~ DATE SIGNED
~ Q~ ~9 f~j~~
PARTNERSHIP/LIMITED PARTNERSHIP (Sig res of gener partners only)
9. PARTNER'S PRINTED NAIi~ (Last, first, middle) SIGNA DATE SIGNED
X
PARTNER'S PRINTED NAME (Last, fast, midde) SIGNATURE
X DATE SIGNED
PARit~R'S PRINTED NAME (Leal, test, middle) SIGNATl1RE
X DATE SIGNED
CORPORATION
10. PRINTED NAME (Last, trst, middle) I SIGNATURE
x PATE SIGNED
TITLE
^ President ^ Vice President ^ Chairman of the Board
PRINTED NAME (Lest, frs4 middle) SIGNATURE !
X DATE SIGNED
TITLE
^ Secretary ^ Asst. Secretary ^ Chief Financial Officer ^ Asst. Treasurer
LIMITED LIABILITY COMPANY
17. The limited liability company is member-run ^ Yes ^ No (If no, complete Item #12 below)
12, NAME OF DESIGNATED MANAGER, MANAIXMG MEMBER OR DESIGNATED OFFICER{Last, flrsl. middle) ABC INITWLS/DAT£ (ABCrRVe Doty)
13. MEMBERS PRINTF~ NAME (Last, tirsl, midde) SIGNATURE
X DATE SIGNED
MEMBER'S PRINTED NAME (Last, first mkidle) SEGNATUR£
X DAT£ SIGNED
ABC-211-SIG (2/03) "SIGN ON"
10a-3
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
State of California
County of SGl .EGe. l.t:~R-Gy
On Dale y ~,t~U ~ before me, ter (~/1 ~1 8 r 1~ ~~ A ~e a> t arU~' ~l? ~ ~~(_T A ~-~c G'.
personally appeared C•U n lt)Cr A E-( I A NCx
rdan,e~sl or slg°ner(s)
who proved to me on the basis of satisfactory evidence to
be the person(s) whose name(s) l~s'are subscribed to the
within instrument and acknowledged to me that
he she/they executed the s e in his/her/their authorized
pacity(ies), and that b hi er/their signature(s) on the
instrument the person(s), or the entity upon behalf of
which the person(s) acted, executed the instrument.
~- KIM N. PRAM ~
V ~ COMM. # 1601639
(~ ~ NOTARY PUBLIC -CALIFORNIA +~
SANTA CLARA COUNTY A
COMM. EXPIRES AUG 19, 2009 '~
Place Notary Seat Above
certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph is
true and correct.
WITNESS my hand and official seal.
,Signature
gnatw Pual~
OPTIONAL
Though the information below Is not required by law, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of thts form to another docirmenL
Description of Attached Document
Title or Type of Document:
Document Date:
Signer(s) Other Than Named Above;
Capacity(ies) Claimed by Signer(s)
Signer's Name:
O Individual
O Corporate Officer -Title(s): _
D Partner - D Limited O General
^ Attorney in Fact
^ Trustee
^ Guardian or Conservator
^ Other:
Signer Is Representing:
Top of Ihumh here
Number of Pages:
Signer's Name:
D Individual
D Corporate Officer - Title(s): _
D Partner - ^ Limited D General
D Attorney in Fact
^ Trustee
D Guardian or Conservator
^ Other:
Signer Is Representing:
Top or Ihtxr~ here
®2007NaBonelNolaryAssoaalbn•!);i50De5doAva.,P.O.Box24tY2•Cha4swor~,CA81373.2402•www.NalionaMolaryarg IlemB5907 Reorder.CaRTdI-Free7•BOD~676.8827
10a-4
City Hail
10300 Torre Avenue
Cupertino, California 95014
Phone (448) 777-3312
Fax (408) 777-3366
OFFICE OF THE CITY MANAGER
SUMMARY
AGENDA ITEM NUMBER
SUBJECT AND ISSUE
Application for Alcoholic Beverage License.
BACKGROUND
1. Name of Business
Location:
Type of Business:
Type of License:
Reason for Application:
RECOMMENDATION
AGENDA DATE Ma 20 2008
Eric Yi (Wang Tofu House}
10789 S Blaney Ave
Restaurant
On-Sale Beer and Wine -Eating Place (41}
Original & Annual fees
There are no use permit restrictions or zoning restrictions which would prohibit this use, and staff has no
objection to the issuance of the license.
Prepared by:
Colin Jung, nio fanner
Submitted by:
~(
David W. Knapp, City Manager
10b-1
Printed on Recycled Paper
Department of Alcoholic Beverage Control
APPLICATION FOR ALCOHOLIC BEVERAGE LICENSE(S)
ABC 211 (G/99)
TO: Department of Alcoholic Beverage Control
100 Paseo de San Antonio
Rm. i 19
San Jose, CA 95113
(408)277-1200
DISTRICT SERVING LOCATION: SAN .iOSE
First Owner:
Name of Business:
Location of Business:
County:
Is premise inside city limits?
Mailing Address:
(If different from
premises address)
Type of license(s): 41
Transferol•'s license/name:
YI ERIC
WANG TOI'U iEIOUSE
State of California
File Number: 466361
Receipt Number: 1661216
Geographical Code: 4303
Copies Mailed Date: April 24, 2008
Issued Date:
10789 S BLANEY AVE
CUPERTINO, CA 95014-4500
SANTA CLARA
Yes
license Tvpe Transaction Type
Census Tract 5080.01
/ Dropping Fortner: Yes No
Fee TvDe aster ~ Date Fee
41 ON-SALE BEER AND ORIGINAL, FEES NA Y 0 04/24/08 $300.00
4I ON-SALE BEER AND ANNUAL FEE NA Y 0 04/24/08 $304.00
Total $604.00
Have you ever been convicted of a felony? N o
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 tvhich shall be deemed part of [his application.
Applicant agrees (a) that any manager employed in an on-sale licensed premise 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: April 24, 2008
Under penally of perjury. each person whose signature appears below, certifies attd says: (I) 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 persat other
than rite applicant or applicants has :tny direct or indirect interest in Utc applicant or applicant's business to he 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 riled 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; (S) drat the transfer application may
be withdrawn by either the applicant or the licensee with no resulting liability to tltc Departtnent.
Applicant Name(s) Applicant Signature(s)
_ ---~ '--~_ ---~ t
YI ERIC •
10b-2
Department of Alcoholic Beverage Control -
APPLICATION TOR ALCO)~IOLIC BEVERAGE LICENSE(S)
AI3C 211 (G/99)
TO: Department of Alcoholic Beverage Control
100 Paseo de San Antonio
Rm. 119
San Jose, CA 95113
(408)277-1200
DISTRICT SERVWG LOCATION: SALT .TOSS
First Owner: YIERIC
Name of Business: WANG TOFU DOUSE
Location of Business;
County:
Is premise inside city limits?
Mailing Address:
(If different from
premises address)
Type of license(s): 41
Transfel•or's license/name:
State of California
File Number: 466361
Receipt Number: 1661216
Geographical Code: 4303
Copies Mailed pate: April 24, 2008
Issued Date:
10789 S BLANEY AVE
CUPERTINO, CA 95014-4500
SANTA CLARA
Yes
License Types Transaction Tape
Census Tl•act 5080.01
/ Dropping Partner: Yes No ,
FeeFee Tvoe Master ~p Date Fee
4l ON-SALE BEER AND ORIGINAL FEES NA Y 0 04/24/08 $300.00
4l ON-SALE BEER AND ANNUAL FEE NA Y 0 04/24/08 $304.00
. Total $604.00
Have you ever been convicted of a felony? N o
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-sate licensed premise 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: Apl-il 24, 2008
Under penalty of perjury, each person rvhose 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 snake this application on iu 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 fulfil] an
agreement entered into more than ninety (90) days preceding the day on which [he 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) Ehat the transfer application may
be withdrawn by either the applicant or the licensee with no t~sul[ing liability to the Department.
Applicant Name(s) Applicant Signatule(s}
YT ERIC '~
10b-3
City Hall
10300 Torre Avenue
Cupertino, CA 95014
(408)777-3212
Fax: (408) 777-33b6
OFFICE OF THE CTrY MANAGER
SUMMARY
AGENDA ITEM NUMBER ~ ~
SUBJECT AND ISSUE
Application for Alcoholic Beverage License.
BACKGROUND
1. Name of Business:
Location;
Type of Business:
Type of License:
Reason for Application:
RECOMMENDATION
AGENDA DATE V~ ~ S
Hofbrau Beer Hall SV, LLC
10123 N Wolfe Road #2124
Restaurant
On Sale General-Eating Place (47)
Annual Fee, Person to Person Transfer,
Premise to Premise Transfer, fingerprinting
There are no use permit restrictions or zoning restrictions which would prohibit this use and staff
has no objection to the issuance of the license.
Prepared by:
t .i ~
Calin Jung, a for an er
G:planning/misdabc hofbraubeerhall
Submitted by:
David W. Knapp, City Manager
10c-1
Printed on Recycled Paper
' Department of Alcoholic Beverage Control
APPLICATION FOR ALCOHOLIC BEVERAGE LICENSE(S)
ABC 211 (6199)
TO: Department of Alcoholic Beverage Control
100 Paseo de San Antonio
Rm. 119
San Jose, CA 95113
(408)277-1200
DISTRICT SERVING LOCATION: SAN POSE
First Owner:
Name of Business:
Location of Business:
County:
Is premise inside city limits?
Mailing Address:
(If different from
premises address)
Type of license(s): 47
State of California
File Number: 466609
Receipt Number: 1662513
Geographical Code: 4303
Copies Mailed Date: May 1, 2008
Issued Date:
HOFBRAU BEER HALL SV LLC
HOFBRAU BEER HAL)G, SV LLC
10123 N WOLFE RD
STE 2124
CUPERTINO, CA 95014-2511
SANTA CLARA
Yes
10123 N WOLFE RD
#2049
CUPERTINO, CA 95014
Census Tract 5081.01
Transferor's license/name: 330040 / AYYALURU ANKI Dropping Partner: Yes
''tense T ~ransactjon Tvne fee TXpe Master Dun P~~
No
Fee
47 ON-SALE GENERAL) PERSON TO PERSON TRANSF p4 Q Y 0 0 5 / 01 / 0 8 $1,250.00
47 ON-SALEGENERALI ANNUAL FEE P40 Y 0 05/O1/OS $758.00
47 ON-SALE GENERAL ! PREMISE TO PREMISE TRANS p 4 0 Y 0 0 5/ O l/ 0 8 $100.00
47 ON-SALE GENERAL I FEDERAL FINGERPRINTS NA •N 2 0 5 / 0 1 / 0 8 $48.00
47 ON-SALE GENERAL 1 STATE FINGERPRINTS NA N 2 0 5/ O 1/ 0 8 $78.00
Total $2,234.00
Have you ever been convicted of a felony? N o
Have you ever violated any provisions of the Alcoholic Beverage Control Act, or regulations of the
Department petrtajning to the Act? No
Explain any "Yes° answer to the above questions on an attachmen[ which shall be deemed part of this application.
Applicant agrees (a) that any manager employed in an on-sale licensed premise 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 AIcoholic Beverage Control Act.
STATE OF CALIFORNIA County of SANTA CLARA Date: May 1, 2008
Under penalty of perjury, each person whose signature appears below, certifies and says: (I) He is an applicant, or one of the applicants, or an
executive officer of the applicant corporation, named in the foregoing application, duty authorized to make this application on its behalf; (2) that
he has read [he 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 wish the Department or to gain or
establish a preference to or for any creditor or tmnsicror or to defraud or injare any creditor of transferor; (5) that the transfer applicatitn may
he withdrawn by either the applicant or the licensee with no resulting liability to the Department.
Applicant Name(s) Applicant Signature(s)
HOFBRAU BEER HALL SV LLC ,Ree 211 Signat>Etre Pagr
10c-2
State of Callfomia
APPLICATION SIGNATURE SHEET {";
• This form is to be used as the signature page for
applications not signed In the District Office.
• Read instructions on reverse before complefing.
• Qtt signatures must be notarized in accordance with
Department of Alcoholic Beverage Control
SIGN ON")
1. OWNERSHIP TYPE (Check aid)
Sole Owner ^ Corporation
g Partnership /^ Limited Liability Company
^ Husband & Wife ^ Other
laws of the State where signed. ^ Partnership-Ltd
2 Fa.E NUMBER (tl any) 3. LICFI~SE TYPE 4. 7RANSACTbN TYPE _
^ OrigiuaI ~ Person to Person Transfer
47 ^ Exchange ~ Premise to~Premise Transfer -
. ^ Other
X
PARTNERSHIP/LIMITED PARTNERSHIP {Sig es of general partners only)
9. PARTNER'S PRINTE6 NAME (Last fist, midrAe) SIGWIT DATE SIGNED
x
5. APPLICANT(S) NAME (Last, ras1, middle)
Hotbrau Beer Hall SV, LLC
8. APPLICANr(S MAILING ADDRES3 (Street addrosslP.O. box, dry, state, zip eotle)
1 OJ 23 Wolfe Rd #2049, Cupertino, CA 95014 Attu: Sue Dibala
7. PREMISES ADDI~55 (Street address. City, xfi code)
10123 N, Wolfe Rd., Suite 2I24, Cupertino, CA 95014
APALlCANT'S CBRTIFlCATION
Under penalty of perjury, each pparson whose signature appears
below
certifies and sa
s: {1) He/She is an a
licant
or o
e of payment of a loan or to fulfill an agreement entered into more than
i
t
(90
d
di
h
d
hi
h
h
,
y
pp
,
n
the applicants, or an executive officer of the applicant n
ne
y
)
ngg t
ays prece
e
ay on w
c
t
e transfer
application Is filed with the Department, (b) to sin or establish a
corporation, named in the foregoing ap lication, duly authorized
lication on its behalf
to make this a
~2) that he/she has read preference to or for any creditor or transferor, or~c) to defraud or
j
dit
f
5
h
h
f
;
pp in
ure any cre
or or trans
eror; (
e trans
) t
at t
er application
the foregoing and knows the contents thereof and that each of the may be withdrawn by either the applicant or the licensee with no
above statements therein made are true; {3) that no person other
than the applicant or applicants has sny direct or indirect interest
in the applicant or appPcant's business to be conducted under the resulting liability to the Department.
1 understand that if 1 fail to qualify for the license or withdraw this
application there will be a service charge ofone-fourth of the
license(s) for which this application is made; {4 that the transfer
~ license fee paid, up to 5100.
application or proposed transfer is not made to
a) satisfy the
soLE owNER ~-
8. PRINTED NAME (Last rrs4 middle) SIGNATURE DAIS gip
PARTNER'S PRINrBD NAME (Last. RrsL ndtldle)
DATE SIGNED
X
PARTNER'S PRINTED NAME {Last fxaL middle) SIGNATURE DATE SIGNED
X
CORPORATION
10. PLANTED NAME (Last, srst, coddle) SIGNATURE - DATE SIGNED
X
TITLE
^ President ^ Vice President Chairman of the Board
PRINTla1 NAME (t.asl; Arsl. mdma) - SIGNATURE ~ ~ DAIS SIGNED
X
11. The limited liability company is member-run ^ Yes ~ No (If no, complete item #12 below)
i2. NAME OF DESIGNATW MANAGER, MANAGING MEAABETt OR DESIGNATFA OFFICER (Last fx . mldrae) A13C BJITIAL
Tm~ ^ Secretary ^ Asst. Secretary ^ Chief Financial Officer ^ Asst. Treasurer
LIMITED LIABILITY COMPANY
l..._. V
+ 19. MEMBER'6 PRtN7®NAME (Last first middle) SIGNATIHiE
L<ia~ ~ x .~
MEMt~YS PRINTED NAME (Last flrsL midrib) SIGNATURE
X
ABG211-SIG (2103) "SIGN ON"
I
1]ATE SIGtJED
MTE (ASC we onry}
~: z~ a~
10c-3
CALIFORNIA ALL-PURPOSE
CERTIFICATE OF ACKNOWLEDGMENT
State of ~ /~i~,~as )
County of ~~J/~ ~~r~ )
{?n f~~~/j ~ l~ ~ before me,
(here insert name ant),tifle of ttfi officer)
personally appeared ~~/~ ~i~ ~/~si~~~ ~~E~
personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose
name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the
same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the
person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
WITNESS my hand and official seal.
tgn re of Notary Public
E1/ELYiV HStAO
~ : ~ COMM. #'1762733 ~
'NOTARY PUBLIC -CALIFORNIA ~
z ~ ~ SANTA CLARA COUNTY
.,
My Comm. Expires Aug. 2Q, 2011
(Seal)
ADDITIONAL OPTIONAL INFORMATION
DESCRIPTION OF THE ATTACHED DOCUMENT
.~,fi''O/~/Ctll~/d1L ~o'/.Y~'~1•-/~ .S/JBG~
(Title or descript of attached document)
{Title or description of attached document continued)
Number of Pages ~ Document Date./J~f. ~ Off''
(Additional information)
INSTRUCTIONS FOR COMPLETING THIS FORM
Arrv aclarowledgment completed in California must contain verbiage exactly as
appears above in the nofm}+ section or a separate acknowledgment foam must be
properly completed and attached to that document. The attl}+ exception is if a
dvcunrent is !o be recorded outside of California. /n such instances, arr}+ alternative
aclatawledgntent verbiage as mrrr+ be printed on such a document so long as the
verbiage does not require the notat7+ to do sotttething that fs illegal jor a notary in
Cal~vrnia (i. e, certifying the authorized capacit}+ of the signer). Please check the
document crnefully for proper notarial wording and attach this jotrn if required.
• State and County infonnation must be the State and County where the document
signer(s) personally appeared before the notary public for acknowledgment.
• Datc of notarization must be the date that the signer(s) personally appeared which
must also be the same date the acknowledgment is completed.
• The notary public must print his or her name as it appears within his or krer
commission followed by a comma and then your title (notary public).
• Print the name(s) of document signer(s) who personalty appear at the time of
notarization.
• lndicatc the correct singular or plural forms by crossing off incorrect forms (i.c.
Ire/shclthey- is /are) or circling dre correct forms. Failure to correctly indicate this
information may lead to rejection of document recording.
• Tho notary seal impression must be clear and photographictrlly reproducible.
Impression must not cover text or Lincs. !f seal impression smudges, re-seal if a
sufficient area permits, otherwise complete a different acknowledgment form.
• Signature of the notary public must match the signature on file with the office of
the county clerk.
:• Additional information is not required but could help to ensure this
acknowledgment is nat misused or attached to a different document.
B• Indicate title or type of attached docurncni, number of pages and daft,
Indicate the capacity claimed by the signer. If the claimed capacity is a
corporate officer, indicate the tit{c (i.e, CEO, CFO, Secretar~bc - 4
• Securely attach this document to fire signed document
CAPACITY CLAIMED BY THE SIGNER
^ Individual (s)
Co orate tcer
fi~/ ~C~Q
(Title)
^ Partner{s)
^ Attorney-in-Fact
^ Trustee{s)
^ Other