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T <br /> Centerville <br /> Special Event Permit Application—on Private Property <br /> 1. TITLE,PURPOS ,ANP B F DESCRIPTION OF EVENT: <br /> New Application: Renewal of or Change in Application: <br /> Has this event been held in the past? II Yes K No If so,when? <br /> CONTACT PERSON: �r G/' 6allah' <br /> TELEPHONE: ( 7*�g 953i OR EMAIL: <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 itsMeir behalf. <br /> Applicant's Name: Title: vwrIchad- <br /> Address: ISO\ M<- �t <br /> Mailing Address: <br /> Affiliation: <br /> Day Phone: C_5%-61%1-CSS6 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. f <br /> Name: ' / / 12� <br /> Organizati n/Bo�itsiness/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: h J• �5 1� <br /> Day Phone: Evening Phone: <br /> Title and functions respo ibili with regard to the even <br /> e Yl e <br /> Page 1 of 5 <br /> 21 <br />