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Department of Alcoholic Beverage Control
State of California
Gavin Newsom, Governor
LICENSED PREMISES DIAGRAM (NON-RETAIL)
1. APPLICANT NAME (Last, first, middle) 2. LICENSE TYPE
3. PREMISES ADDRESS (Street number and name, city, zip code) 4. NEAREST CROSS STREET
The diagram below is a true and correct description of the entrances, exits, interior walls and exterior boundaries of
the premises to be licensed, including dimensions .
DIAGRAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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It is hereby declared that the above-described premises and character of premises, as indicated on the reverse side, will
not be changed in accordance with Rule 64.2 of the California Code of Regulations without first notifying and
securing written approval of the Department of Alcoholic Beverage Control. Substantial changes to the premises may
require an application fee in accordance with Section 24072 of the Business and Professions Code. I declare under
penalty of perjury that the foregoing is true and correct.
APPLICANT SIGNATURE (Only one signature required) DATE SIGNED
FOR ABC USE ONLY
CERTIFIED CORRECT (Signature) PRINTED NAME INSPECTION DATE
ABC-257-NR 2-sided (rev. 10-19)
)
Department of Alcoholic Beverage Control
PLANNED OPERATION (NON-RETAIL)
1. APPLICANT NAME(S) (Last, first, middle) 2. LICENSE TYPE(S)
3. PREMISES ADDRESS (Street number and name, city, zip code)
4. PREMISES (Check all that apply)
Office Warehouse Production Facility Alternating Proprietorship Tasting Room Joint Tasting Room
Restaurant on Premises
5. MANUFACTURE
Beer Wine Distilled Spirits
IMPORT
Beer Wine Distilled Spirits
WHOLESALE (Distribute)
Beer Wine Distilled Spirits
6. SELL TO
Retailers Wholesalers Consumers Export out of California
7. OPERATING HOURS
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Opening Time
Closing Time
8. LIST ANY BRAND NAME(S) AND TYPE(S) OF ALCOHOL PRODUCT YOU WILL MANUFACTURE/IMPORT/DISTRIBUTE
9. IF CONTRACTING WITH A MANUFACTURER TO MAKE A CUSTOM PRODUCT TO BE SOLD UNDER YOUR BRAND NAME LIST NAME AND LICENSE NUMBER OF MANUFACTURER.
10. LIST NAME(S) AND ADDRESS(ES) OF ALL SUPPLIERS OF ALCOHOLIC BEVERAGES (Street number and name, city, state, zip code)
11. ALCOHOLIC BEVERAGES WILL BE SHIPPED TO MY CUSTOMERS FROM (STREET NUMBER AND NAME, CITY, STATE, ZIP CODE)
Applied-for p remises
Type 14 (Public Warehouse) ABC License Number Address
Other ( E.G.Duplicate 02) ABC License Number Address
12. ALCOHOLIC BEVERAGES WILL BE STORED AT (Street number and name, city, state, zip code) 13. BUSINESS RECORDS WILL BE MAINTAINED AT (Street number and name, city, state, zip code
14. FEDERAL BASIC PERMIT REQUIRED FROM ALCOHOL AND TOBACCO TAX AND TRADE BUREAU (TTB)?
Yes No APPLICATION DATE
15. IF APPLYING FOR TYPE 02 WINEGROWER LICENSE OR TYPE 22 WINEBLENDER LICENSE, LIST BONDED WINERY PERMIT NUMBER ISSUED BY TTB (REQUIRED)
BONDED WINERY PERMIT NUMBER
16. REGISTRATION REQUIRED FROM STATE BOARD OF EQUALIZATION?
Yes No REGISTRATION DATE
FOR ABC USE ONLY
INFORMATION PROVIDED
ABC-579 Instructions to Beer Suppliers
ABC-413 Instructions to Distilled Spirits Shipper
ABC-414 Distilled Spirits Shipper Agreement
PROVIDED BY (Name) DATE PROVIDED
COMMENTS/ADDITIONAL INFORMATION
ABC-257-NR 2-sided (10/19)
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Completed 21 February 2022

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