Application For Extension Of Premises/patio Permit - Arizona Department Of Liquor Licenses And Control Page 2

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Barrier Exemption: an exception to the requirement of barriers surrounding a patio/outdoor serving area may be
requested. Barrier exemptions are granted based on public safety, pedestrian traffic, and other factors unique to a
licensed premises. List specific reasons for exemption:


Approval
Disapproval by DLLC:
_________________________________________________________
Date: _____/_____/______
Notary
I,
,
hereby declare that I am a CONTROLLING PERSON/ AGENT filing this
(Signature)
notification. I have read this document and the contents and all statements are true, correct and complete.
State of Arizona
)
)
County of ________________ )
On this _____Day of ____________, 20_______ before me personally appeared ________________________________
Day
Month
Year
(Print Name of Document Signer)
Whose identity was proven to me on the basis of satisfactory evidence to be the person who he or she claims to be and
acknowledged that he or she signed the above/attached document.
________________________________________________
Signature of NOTARY PUBLIC
(Affix Seal Above)
GOVERNING BOARD
After completion, and BEFORE submitting to the Department of Liquor, please take this application to your local Board
of Supervisors, City Council or Designate for their recommendation. This recommendation is not binding on the
Department of Liquor.
Approval
Disapproval
________________________________________________________________________________________________________________________
Authorized Signature
Title
Agency
Date
DLLC USE ONLY
Investigation Recommendation:
Approva
l
Disapproval by:
_________________________________ Date: ____/____/____
_____________________________________________________
Director Signature required for Disapprovals:
Date: ____/____/____
1/25/2017
Page 2 of 2
Individuals requiring ADA accommodations please call (602)542-9027

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