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' teryitTe <br /> Centerville <br /> Special Event Permit Application <br /> 1. TITLE, PURPOSE, AND BRIEF DESCRIPTION OF EVENT: q S r <br /> New Application: Renewal of or Change in Application: <br /> CONTACT PERSON: J 4 ' 14 � C,6, dii,, 5 <br /> TELEPHONE: 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 . <br /> r this special event permit on its /their behalf <br /> Applicant's Name: JL)�oj /_' u C Co'i 6,r)1 Title: <br /> Address: - 1 (2A 41- D <br /> Mailing Address: <br /> Affiliation: <br /> Day Phone: ( Sk . y2{p . � j(_Evening Phone: �0 U <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. A <br /> Name: (L L �C 1 t /� WO � 0 <br /> Organization/Business /Agency /Affiliation: <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: <br /> Day Phone: _ 0`� Evening Phone: <br /> Title and functional responsibility with regard to the event: h P q rat C4r j( 'LP <br /> Page 1 of 10 <br />