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C <br /> tL f Cr7JZftC <br /> ',j Centerville <br /> Special Event Permit Application - on Private Property <br /> 1. TITLE URPOSE AND BRIE DESCRIPTION OF EVENT: <br /> ^ (` <br /> New Application: E/ Renewal of or Change in Application: <br /> Has this event been held in the past? 1 ° Yes No If so, when? Cirirw -a <br /> CONTACT PERSON: joviet -4(4 e <br /> TELEPHONE: (15-1 -y Z -'� U - OR <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: Title: LLSin- SS m�ntS r <br /> Address: - 1 C�; o, -n, EA <br /> Mailing Address: mN 5 3s; <br /> Affiliation: I - <br /> Day Phone: Evening Phone: <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: Gre ct -S a J ( c crF Si (ge ne ✓1 Jr - <br /> Organization/B /Agency /Affiliation: ?a S to t <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: 'sa ina s <br /> Day Phone: Evening Phone: <br /> Title and functional responsibility with regard to the event: <br /> Page 1 of 6 <br /> 6 <br />