Isis Shrine Termporary PermitAlcoholic Beverage Control
109 SW 9th Street, 5th Floor
PO Box 3506
Topeka KS 66601-3506
Mark A. Burghart, Secretary
TEMPORARY PERMIT LOCATION AND ZONING
Phone: 785-296-7015
Fax: 785-296-7185
kdor _ abc.email@ks.gov
www.ksrevenue.gov
Laura Kelly, Governor
Applicant Name: /s;s 5'br:~t FEIN/SSN: Yf-0;?711.,,fe,Q
Phone Number: 785-&:?S~D:Jola Event Date(s) (must be consecutive): Oct 15, ;Jo;;.¢
Event Type: t;!J:haritable Auction (Jpn-Premise g Porcelain Container ~ecial Event* -Number of days: ____ _
*A special event is held on public streets. allevs. roads, sidewalks or hiqhwavs and must be approved, by ordinance or resolution, by the local
governing body of any city, county or township where such special event is being held.
SECTION 1 -EVENT AREA: Complete this section for On-Premise and Special Events only.
In the space below, draw the floor plan and any outside areas included in the proposed event area where alcoholic liquor will be sold,
served, or consumed. If the area is outside, it must show the line of demarcation to define the event area; and , include nearby streets
for reference. Shade in the areas you DO NOT wish to be permitted.
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SECTION 2 -CERTIFICATE OF CITY, TOWNSHIP OR COUNTY CLERK: (Completed by the clerk)
1 HEREBY CERTIFY THAT THE PREMISES AT 200 E Dia.roond. :Dr-i"L .Soli.V\a , Ks CJ,1'io\
Location Street Address City ~;sss:?. ~~
CITY LIMITS : irglnside the incorporated city limits IOOutside the city limits
ZONING: within an area that complies with all applicable zoning regulations required by K.S.A. 41-1201(e)
!Clocated outside an incorporated city, in a township or county that is not zoned 'to~~ 1
LOCATION: jggovernment property ~private property {!L)ublic property Q CMB licensed premise 0 :
nowledge and believe that sr_ctiyn 2 is true, correct, a PIJ.~S?.letl!'!J ./P
CLERK SIGNATU """--...,...W,-J~~~~~~-=:::..--DATE 9/Q/2!--PHONE :· • •• C:)
ABC-892 (Rev. 08/22)