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PARK FACILITY PERMIT APPLICATION <br /> 1. Name /Address/Phone Number of Individual or Organization responsible for <br /> making this application: <br /> Kim Brouillet 6434 Pheasant Hills Dr <br /> Name Address <br /> 651- 269 -5652 Lino Lakes, MN 55038 <br /> Telephone Number City, State & Zip <br /> 2. Please describe your event/activity and identify the specific facility /field within <br /> the park you wish to use along with what you are asking from the City: <br /> Lamotte ark: Ice Rink/Warmin house <br /> g se <br /> 3. What is the number of people that are involved in your event/activity? 20 <br /> 4. What City facilities do you wish to use <br /> Acorn Creek Park Eagle Park _ <br /> Laurie LaMotte Memorial Park Hidden Spring Park <br /> (Lighting & Warming House) Trailside Park <br /> Cornerstone Park Royal Meadows Park �— <br /> Tracie McBride Memorial Park � City Hall <br /> 5. Please list the date or dates and times you propose to use the facilities: <br /> Tuesdays 5 -8pm starting 10/23/12 thru 2/26/13 <br /> 6. Is anyone charged a fee to watch or participate in your event? NO <br /> 7. Have you used these facilities before? YES If so, when? <br /> Winter Season 2010 -11: B1 Squirt Hockey <br /> 8. Are you requesting additional permits or City services? Yes No <br /> (i.e., Road Closure(s), Temporary Liquor License(s), Fireworks Permit or <br /> Burning Permit, Use of lights, bathrooms or porta potties, Park Buildings) <br /> Please describe <br /> Depending upon the nature of your event, or if you are requesting City services, you may <br /> be required complete a different application and/or make a deposit to cover city costs. <br /> Kimberley Brouillet 10/16/2012 <br /> Printed Name of Person Signing Date \ ti <br /> Signature \ <br /> Office Use Only 45 <br /> Permit approved by: ' Date: 1,61?-32_ <br /> Deposit required: $ /00. r ' Receipt # gs16 <br /> Form number: 2012.04 PU <br />