Fillable Cannabis Renewal Permit Non Dispensary 091919 (City of Oakland)

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Cannabis Renewal Permit Non Dispensary 091919 (City of Oakland)

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2020CannabisRenewalPermitApplication1



SPECIAL ACTIVITY PERMITS • 1 Frank H. Ogawa Plaza, 1st Floor • Oakland, CA 94612



2020CANNABISRENEWALPERMITAPPLICATION



ApplicantInformation:



Name:_______________________________________________________________________



GeneralApplicantNotIncubatingEquityApplicant



GeneralApplicantIncubatingthefollowingequityapplicant(s):



_____________________________________________________________________________________



DoingBusinessAs

:____________________________________________________________________



AddressofPermittedCannabisOperation:



_______________________________________________________________________________________

AddressUnit#ZipCode



Partner/Owner/ManagerInformation:

Pleaselistallpersonsdirectlyorindirectlyinterestedinthepermitsought,includingallofficers,directors,generalpartners,

managingmembers,stockholders,andpartners.Pleaseattachadditionalpagesifnecessary(additionalpagesshouldbeon

8½x11”paper;singlesided,andincludeaHeaderwiththeapplicant’snameonthetop

rightcornerofeachpage).



LastName: FirstName: MiddleInitial:

Alias(es): Title:

DateofBirth: Phone: Email:

ResidentialAddress:

City: State: Zip:

BusinessAddress:

City: State: Zip:



LastName: FirstName: MiddleInitial:

Alias(es): Title:

DateofBirth: Phone: Email:

ResidentialAddress:

City: State: Zip:

BusinessAddress:

City: State: Zip:



CITY OF OAKLAND

Office of the City Administrator

2020CannabisRenewalPermitApplication2



LastName: FirstName: MiddleInitial:

Alias(es): Title:

DateofBirth: Phone: Email:

ResidentialAddress:

City: State: Zip:

BusinessAddress:

City: State: Zip:



TypeofLicense:(Pleasecheckallthatapply)



MedicalAdultUseMedicalandAdultUse



 DeliveryOnly‐DispensaryIndoorCultivatorGreenhouseCultivator



 DistributorTransporterTestingLaboratory

 

Packaging



Manufacturingwithvolatilesolvents Manufacturingwithnon‐volatilesolvents

 ExtractionExtraction

 InfusionInfusion

 PackagingPackaging



ProjectedAnnualGrossReceipts:



Cannabissales<$500,000 Cannabissalesbetween<$500,001‐$999,999Cannabissales>$999,999



CommunityBeautificationPlan



Pleasesubmita

briefstatementastothecommunitybeautificationactivitiesthatyouengagedinoverthepast

yeartoreduceillegaldumpingandgraffitiwithin50feetofyourplaceofbusiness.



2020CannabisRenewalPermitApplication3



OathofApplication

I,theundersigned,declareunderpenaltyofperjurythattothebestofmyknowledge,theinformationcontained

inthisapplicationanditssupporting documentationistruthful,correctandcomplete;and,theinformation

containedinthisapplicationanditssupportingdocumentationdisclosesallfactsregardingtheapplicant

and

associatedindividualsnecessarytoallowtheCityAdministratortoproperlyev aluatetheapplicant’squalifications

forregistration.



I,theundersignedfurtheragreeandacknowledgethatImayberequiredtoprovideadditionalinformationas

needed,foracompleteinvestigationbytheCityAdministrator.



I,theundersigned,furtheragreeandrecognize

thatIamresponsibleforobeyingallFederal,State,Countyand

locallaws.



I,theundersigned,furtheragreeandunderstandthatanymisrepresentations,omissionsorfalsificationsinthe

applicationoranydocumentsattachedtheretooramendmentstheretowillbeimmediategroundsfortheCity

Administratortodenythispermitapplication

and/orimmediategroundsforrevocationofacannabispermit.



APPLICANTNAME:

SIGNATURE:

DATE:



FOROFFICEUSEONLY:



DateReceived:____________________________DateProcessed:_________________________



DocumentsReceived:



 ForGeneral&Equity

 FireInspectionReport

CopyofStateTemporary,ProvisionalorAnnualLicense



ForGeneralOnly

FeesPaid



ForEquityOnly

2018FederalTaxReturn

Documentforcurrentresidencyverification



By:______________________________________________________________________





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Cannabis Renewal Permit Non Dispensary 091919 (City of Oakland)

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Completed 23 July 2020

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