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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 /> Stephanie Gavin 2008 Willow Circle <br /> Name Address <br /> 612 - 202 -5394 Centerville, 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 /> Daughter's dedication - August 18, 2013 <br /> 3. What is the number of people that are involved in your event/activity? 50.40 <br /> 4. What City facilities do you wish to use <br /> Acorn Creek Park Eagle Park <br /> Laurie LaMotte Memorial Park X a vJ /ta .— Hidden Spring Park <br /> (Lighting & Warming House) Trailside Park <br /> An adult may be requested to take <br /> responsibility to lock & unlock restrooms <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 /> August 18, 2013 <br /> 6. Is anyone charged a fee to watch or participate in your event? No <br /> 7. Have you used these facilities before? No If so, when? <br /> 8. Are you requesting additional permits or City services? Yes X 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 /> P G ti �, 7 -30 -2013 <br /> Printed Name of Person Signing Date <br /> / r .�. <br /> S ignature <br /> Office Use Only <br /> Permit approved by: Date: %0/3 <br /> Deposit required: $ /no. °O Receipt # 237 <br /> Form number: 2013.01 PU <br />