Appendix A
VILLAGE OF PAWNEE, ILLINOIS
APPLICATION FOR ADULT USE PERMIT
Directions to Applicant: All information requested must be supplied.
Use a continuation sheet if needed.
The undersigned hereby applies for an adult use permit from the Village of Pawnee in accordance with Title 12 of the Village of Pawnee Code of Ordinances.
1. Name, address and telephone number of applicant:
2. Type of business entity:
None–the applicant is an individual or individuals. If proposed use is "adult club" as defined in Title 12 of the Pawnee Code of Ordinances, identify all members on a separate sheet.
Corporation* LLC*
Other–please specify
*Attach a certificate of good standing from the Illinois Secretary of State.
3. Names and addresses of all persons with a 5% or greater ownership interest in the applicant, if the applicant is other than an individual or individuals:
4. Name and address of person to contact regarding this application, and such person's relationship to the applicant:
5. Address and legal description of the premises at which the adult use will be conducted:
6. Nature of applicant's interest in the premises:
Ownership (attach copy of deed) Leasehold (attach copy of lease)
Contract for deed (attach copy of contract)
Other (please specify and attach evidence of interest)
7. Narrative description of intended use of the property:
8. Names, addresses and phone numbers of managers of adult use:
9. A site plan and floor plan drawn to scale, identification of construction materials, and plans for lighting, parking and circulation, ingress and egress, landscaping and screening, and signage, are attached.
I hereby certify under penalty of perjury that the foregoing statements are true and correct. I have reviewed Title 12 of the Village of Pawnee Code of Ordinances and will abide by its terms. I attach a check in the amount of $350 to cover the cost of the permit application.
Signature:
Date:
For Zoning Administrator's use only
Present zoning of the property:
Zoning classifications and uses of all properties within 1000 feet of property line:
Recommend Approval Recommend Denial for the following reasons:
Signature: Date:
For Planning Commission's Use Only
Recommend Approval Recommend denial, for the following reasons:
Minutes of the Planning Commission hearing on this application are attached.
Date:
For Chief of Police Use Only
I have performed a criminal background check on all persons listed in this application as owners of a 5% or greater interest in the applicant or as the manager of the facility. I find that:
no such persons have been convicted of the crimes of prostitution or obscenity, or other crimes of a sexual nature.
the following persons listed in this application have been convicted of the crimes of prostitution or obscenity or other crimes of a sexual nature:
Name Date of Conviction Description of Crime
Date Chief of Police
For Village Clerk's Use Only
This application was approved denied by action of the Village Board of the Village of Pawnee on pursuant to Resolution No. .
Village Clerk
(Ord. 01-15, 10-22-2001)