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APPLICATION FOR AMUSEMENT DEVICE LICENSE (Section 55-21 through 55-26 of Lafayette Municipal Code) Applicant Address: Address Where Devices Are Located (if different) LIST TYPE & NUMBER OF DEVICE & FEE Applicant affirms that he is familiar with Section 55-21 through 55-26 of the Municipal Code relative to amusement devices and coin operated music machines, video games, and the licensing thereof. Applicant’s Signature Date FILING INSTRUCTIONS: This application must be submitted to the Lafayette City Clerk’s Office prior to January 1 of each year with $100/year for each amusement device up to 10 and $35/year for each exceeding ten at each location. Coin operated musical devices are $25/year for each device. FOR OFFICE USE ONLY License Expiration Date By City Clerk 1290 S. Public Road, Lafayette CO 80026 (303) 665-5588