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55( ]3,uirfl[,eir _a[ie ]3,ou�evard ",,W <br /> Ainolka County Airodover, VU',,N5!53()4, <br /> PARKS & RECREATION 7 6 3 2 4,3 3()() <br /> Ojolen SJON:)CE�S 111 ',,Jearb.,),,� '-�Iaces 763,324,3301 0`ax) <br /> SPECIAL USE PERMIT REQUEST FORM <br /> Today's Date: Jan 21, 2019 Date of Event:July 20, 2019 Arrival Time: 07:30 Departure Time:8:30 <br /> Park: Rice Creek Chain of Lakes Regional Park Pavilion/Shelter/Meeting Room # or Name:1AA 0§ <br /> Name of Organization: Centerville Parks and Recreation Committee <br /> Address: 1880 Main Street City: &QWM i I� ZIP:-§§§W <br /> Contact Name:Patrick Branch Email Address: <br /> 4P91m, <br /> Phone Number: Primary: (703 501-6815 Secondary: @§11 <br /> Number of People Attending your Event'. 1160 <br /> Requested Special Use Activity <br /> Please describe special activity requested and location of activity as it relates to reserved shelter/pavilion/meeting room: <br /> IT4 111M sfiwml F@I@ d@§IL06§_W RM§K fYn§.. Thii§ii§A-W @Y@N MMO%d&Mgkiviil"a-WRYM g@10096fi F61@ d@§Um§.- <br /> Specific Time Special Use Activity Will Take Place in Park: kwwssmill M06151 Me tymk Rvmil-7.§9 §Okw*A <br /> Indicate Additional Set-Up and Take-Down Time (if beyond reservation hours): rwtmw�g <br /> Does Activity Require Electric Hook-Up? Yes No How many? <br /> Does Activity Require Water Hook Up? YesE-1 Noll)" <br /> Office Use Only Approved by: <br /> Title: <br /> ...... Approved Date: <br /> ....................................................................................................................................................................... <br /> Not Approved <br /> ...... Notes: <br /> Additional Fees <br /> Tent [$25] <br /> Maintenance Fees [$25 hour] <br /> Other <br /> ........................................................................................................................................................................ <br />