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.♦ 1i4 <br /> Anoka County Parks and Recreation <br /> a uq <br /> 550 Bunker Lake Boulevard NW, Andover, MN 55304 <br /> SPECIAL USE PERMIT REQUEST FORM <br /> Todoys Date: 1 '"Date of Event: '> j7 �.� Park: RX Lf Ceb'iC <br /> Pavilion /Shelter /Meeting Room Number or Name: N14 Arrival Time: .'3 O Departure Time: 1 t� <br /> Name of Organization: Ce t& R w 1-4a 1 ks d' l ?G'Z Ce ywp,t r. 1* <br /> Contact Name: J Air r-J, 131? *1ejC11 <br /> Address' G/ ! ' N 'hSV5 lit 0 6[r 14rvit ci e4rA LTV1 iz. Z ip: s�d� 8 <br /> Phone Number: Home: { 03 1 JAI 6V s Work: (�� Fax: <br /> Number of People Attending your Event: // 0 — / "-J'r <br /> Requested Special Use Activity (please describe special activity requested and location of activity as it relates to reserved <br /> shelter/ pavilion/ meeting room): P * r Sae d w J'o a y a fr GG we is rx4. L r-at 4 Muni j w�► Z ! r <br /> -e- vr.vT, A''7A*t15Sf .0v 74j vs..- t;c,*ey ,hc- Rc.cL ifp lea" r-w <br /> 14At,o iw- L,.tuc.- e 1UP4 ni.,- e6*,0r <br /> sc �A_rA d Ai .a <br /> Specific Time Special Use Activity Will Take Place in Pork: '3 a -� y;,�a , .14 <br /> I <br /> Indicate Additional Set -Up and Take -Down Time (if beyond reservation hours): QV/¢ <br /> Does Activity Require Electric Hook - Up? Yes _ No V How many? Does Activity Require Water Hook Up? Yes , No <br /> For Office Use <br /> Approved Not Approved <br /> AddiYwrtal Fees <br /> Tent [$25] <br /> Maintenance Fees [$25 / hour] <br /> Other <br /> APPS <br /> br- <br /> Tifle: <br /> Date: Revised 7/25/07 dhs, Revised 8/2!07 md, Revised 10/18/07 and <br /> OPEN SPACES IN NEARBY PLACES <br /> PhnnP: 7A 'A.757 R99n www nnnknt- n»ntvnnrkc r`nm Fnx• 7A1 7 A n7v <br />