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Centerville <br /> Special Event Permit Application pp <br /> 1. <br /> TITLE P�JRPOSE, AND B F DESCRIPTION OF EVENT: S <br /> t - c, u!" ��ems+/o c 1 py�arC, 1 }�• _ S -�S c..n <br /> r.. hca G.IT P� 0 , ar,e (3 <br /> New Application: Renewal of or Change in Application: <br /> CONTACT PERSON: <br /> TELEPHONE: G $1 / C. S 3 7 c/W OR S Z 6 g <br /> 2. IDENTIFYING INFORMATION: <br /> Attach a written communication from the organization(s) in whose name the event will be advertised which <br /> authorizes you, the applicant, to apply for this special event permit on its /their behalf. <br /> Applicant's Name: 6v% A i Title: 1 /� <br /> J4 s . LL,-,A <br /> Address: / � (o G + h 5 i' - <br /> Mailing Addr s: W)- .}t 6,&V Lc, M ed 3 511 <br /> Affiliation: .,� r <br /> Day Phone: la 51 G S 3 -- 74o i Evening Phone: 631 - LIZ, f3 - 9 7 <br /> Emergency Phone: <br /> 3. EVENT PRINCIPALS: <br /> Following, please list the names, addresses and telephone numbers of all the principals involved in any of the <br /> proposed special event. Include professional event organizers, event promoters, financial underwriters, commercial <br /> sponsors, charitable agencies for whose benefit the event is being produced, the organization(s) in whose name the <br /> event is being advertised, and all others administratively, financially and organizationally involved as principals in <br /> the production of the proposed special event. Make additional copies of the following as needed to include as of the <br /> principals involved in the proposed special event. <br /> Name: �-t rf �, <br /> Organization/Business /Agency /Affiliation: (r, d•��st ��� <br /> Is this a non - profit organization? Yes No <br /> If you are making application under non - profit status, proof of non - profit status must be attached to this application <br /> Mailing Address: 4-1 y q 5 L� K A A- R-le'r(u J4 AA/ <br /> Day Phone: 5 i - ZS 1 - 5 21 R q Evening Phone: 6 , S1 - Ll 1 7- - 4� L ' <br /> Title an functional responsibility with regard to the event: <br /> Page 1 of 10 <br />