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07/26/2011 14:45 6516345137 <br />vik <br />1245 W Hwy 96 • Arden Hills MN 55112 <br />Phone 651.792.7500 • Pax 651.634,5 1 <br />www,ci. rden hillsimn.us <br />Properly IT11.01'M a lion <br />Applicant Name and Social Security Number per State Statute 2700,72, Subd. 3 <br />Tom Flaherty <br />CITY OF ARDEN HILLS <br />PAGE 02 <br />Permit # 2011 - <br />License Fee Fundraiser fQr St..1ude - Na fey <br />2011 OutiIOOr Concert license <br />1111111.1 I.••— ••••••••••I II I O•• ow.._. A.. ..• °• °•_...ar.111H•p.s..w...._ IY 11.1 °•�••• ^n.11111. _..u.__.._d II <br />Address: <br />1273 W County Road E, Arden Hills, MN 55112 <br />.111.1•_............_.III Ip. w. ....w.._..I.I.•.•-- ••_.__..�.NI I.p_._._._......bll• p. p......._...MI.N.w.._.._.....HI al 1.._..._�...a aNl..........._.1lLI t.p.... <br />LocniPhoncil <br />651 - 533.1777 <br />1._.��..r.. 11111 .1._._..._._I.NII.'•_._._n_..�1 <br />Local Fax $I <br />651- 633.'3086 <br />F %,t :nl.1itfur]i I1i0Tl <br />Business Name; <br />Flaherty's Arden Bowl <br />NV IV? <br />Address; <br />12731 County Road E <br />Contact Nnmc: - <br />Tom Flaherty <br />Date cif Event <br />— <br />August 20, 2011 <br />Ret1ttircd S111)Tilit1:# iS <br />II11I P.... - -- ......1111/ 1•_. ._.__..s..1111111.............. .111111111........_..._...... -r <br />MN Tax ID # (per State Statute 207C.72, 2, Su17d. 3) <br />9278934 <br />� 1111.•• •••••• 11111111•'•'_._.._..._ p.1111.'• •_.. Ip11111I.••_ _._.._._._... -- 3) <br />Federal Tax ID # (per State Statute 207C.72, Svhd. <br />41- 6028894 <br />E CcntactPhonc Number: <br />651- 633 -1777 <br />City, <br />1 . „.• Slate, Arden Hills MN <br />Estimated Number of Attendees <br />260 (depending on weather) <br />Contact Fax Number: <br />651 - 633 -3086 <br />awr <br />Zip; <br />55112 <br />Hours of Event <br />Music starts at 5:00 p.m. and will run <br />no later than 9 :00 p.m. <br />• - Insurance of at least $100,040 for bodily injury to any one person, including accidental death, <br />Certificate of Liability Insuran <br />and not less than $00,400 aggregate; property <br />ate• damage liability of at least $100.000 for each accident and not Tess than <br />$100,000 aggregate. <br />Certificate of Worker's Compensation to the minimum acceptable levels of the State of Minnesota. (attached) <br />Diagram i of event layout including parking are event seating, booths, stage, etc. ( attached) <br />C� �g Y <br />Written permission of property owner. (Applicant is property owner.) <br />Applicant Signature <br />r 4 <br />FOR C_,1-11/ USE ONLY ('when upJ rier►'IL): <br />.11•••�_.w_.. <br />COM. DEVELOPMENT <br />CONMMERCIAL INSPISCTOR <br />y.wlnl- <br />CITY CONCH_ <br />I• <br />VIEW <br />Appro ed ; <br />App <br />Approve <br />(t` <br />HI <br />Date <br />Denied: <br />ypnl•._ <br />Oenied; <br />.r11__ <br />Denied; <br />.11 <br />Date; <br />Date; <br />Date: <br />