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<br />Centerville <br />Special Event Permit <br /> <br />NAME AND TYPE OF EVENT: PA /L --rob~ iIIE:J11 f)tZ-J if L J1,/YJfZFrr- <br /> <br />DAY, DAm AND TIME: s"f. L.8f C(!} ///MJ 4q; - //"4t:Jpm <br /> <br />1. PARKS AND RECREATION DEPARTMENT <br />FINAL APPROVAL AND SIGN OFF <br /> <br />Signature Title <br /> <br />Date: <br /> <br />Please check or use N/ A (not applicable) where appropriate: <br />1. Final check has been made of application requirements. <br />2. Event is approved by City Council. <br />3. _ All required permits are issued and on file. <br />4. Refundable clean up fee has been paid. <br />5. _ Insurance Certificate 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 complete. <br />8. Special conditions are attached. <br /> <br />REVOCATION: Upon mutual consent, the City Council may revoke a special event permit if <br />the conditions set fourth in the permit application are not being followed. <br /> <br />Permit is hereby revoked: <br /> <br />Signature <br /> <br />Title <br /> <br />Date: <br /> <br />~;.Reason( s) for revocation: <br /> <br />TO BE REVIEWED/APPROVED AND SIGNED BY AFFECTED <br />CITY DEPARTMENT HEADS <br /> <br />Page 1 of 10 <br />