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Centerville <br /> Special Event Permit Application-on Private Property ,,�� <br /> 1. TI , PURPOSE,AND BRIEF DESCRIPTION OF EVENT: 60h C YX <br /> A10,4,1 Ali <br /> New Application: A.171 Renewal of or Change in Application: <br /> Has this event been held in the past? n Yes jZ No If so,when? <br /> CONTACT PERSON:, tY \Gti <br /> TELEPHONE: I - 10 OR EMAIL: f ej U <br /> S - `S <br /> 2. IDE DYINGSI INFO TIOSS N: <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: Leww Title:.& axSQ�. L=W1hD'> <br /> Address: ITSV,j I l t M AJ S5(Y>t <br /> Mailing Address: J:j'7>QN <br /> Affiliation: <br /> Day Phone: Ccf�,\- 711- S(Qu(u Evening Phone: (psl- 2-TI - Y&tj <br /> Emergency Phone: (6S1 - 'Z-TI - $ (n N O <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:' B MV\ ,( <br /> Organization/B ' <br /> Is this a non-profit organization? Yes No <br /> If you are making application s�under non-profit status,proof of non-profit status must be attached to this application <br /> Mailing Address: ���'13 ��Cl V C'% , b!' S"53 71 <br /> Day Phone: CA51_ -17A- -7-(P-T o vening Phone: <br /> Title and functional responsibility with regard to the event: <br /> Page 1 of 5 <br /> 1 - <br />