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Centerville <br /> Special Event Permit k)(.t� , _ --fn <br /> NAME AND TYPE OF EVENT: V IC.— <br /> DAY, DATE AND TIME: /Z'7 ' ) LI '7� OU <br /> 1. PARKS ANP RECREATION DEPARTMENT <br /> FINAL AP OVAL AND SI <br /> c_, a..._ <br /> Signat re Title <br /> Date: <br /> Please check or use N/A (not applicable)where appropriate: <br /> 1. Final check has been made of application requirements. <br /> 2. Event is approved by City Council. <br /> 3. All required permits are issued and on file. <br /> 4. Refundable clean up fee has been paid. <br /> 5. Insurance Certificate is on file with City Clerk <br /> 6. Surety Bond is on file to secure payment for applicant's obligation to the <br /> City. <br /> 7. Application is complete. <br /> 8. Special conditions are attached. <br /> REVOCATION: Upon mutual consent, the City Council may revoke a special event permit if <br /> the conditions set fourth in the permit application are not being followed. <br /> Permit is hereby revoked: <br /> Signature Title <br /> Date: <br /> Reason(s)for revocation: <br /> TO BE REVIEWED/APPROVED AND SIGNED BY AFFECTED <br /> CITY DEPARTMENT HEADS <br /> Page 6 of 10 <br /> P17 <br />