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Centerville <br /> Special Event Permit <br /> ' NAME AND TYPE OF EVENT: <br /> DAY, DATE AND TIME: <br /> 1. PARKS AND RECREATION DEPARTMENT <br /> FINAL APPROVAL AND SIGN OFF <br /> Signature Title <br /> Date: <br /> Please check or use N/A (not applicabie) where appropriate: <br /> l. Fina) check has been made of application requirements. <br /> 2. Event is approved by City Council. <br /> 3. All required perimits are issued and on file. <br /> 4. Refundabie clean up fee has been paid. <br /> 5. Insurance Ce�rtificabe is on file with City Clerk <br /> 6. Surety Bond is on file to secure payment for applicant's obligation to the <br /> City. <br /> 7. Application is camplete. <br /> S. Special condiihans are attached <br /> RE�O�ATIO�I: Upon mutual c�onsealt, tire City Council may revoke a speeial event peimilt if <br /> it�e con�iitions s�t foutth in the per+mit ap�licatiun are not beimg followed. <br /> P+�it is hereby r+e�oked. <br /> Signatut�e Tifle <br /> �: <br /> R,e�.s��s) fmr revocatio�:: <br /> 'T�O B� R�`9I�1��D�'?1PPR0� A�D �I�� BY AFFEGTED <br /> �t"1'Y DEP�IR"1'1NI�flVPT H���DS <br /> 1'���ff'1� <br /> 28 <br />