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<br />- ----------- - --------- --------- <br /> <br />Centerville <br />Special Event Permit <br /> <br />NAME AND TYPE OF EVENT: <br /> <br />DAY, DATE AND TIME: <br /> <br />1. PARKSANDRECREATIONDEPARTMENT <br />FINAL APPROVAL AND SIGN OFF <br /> <br />Signature <br /> <br />Title <br /> <br />. Date: <br /> <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 /> <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 /> <br />Permit is hereby revoked: <br /> <br />Signature <br /> <br />Title <br /> <br />Date: <br /> <br />Reason(s) for revocation: <br /> <br />TO BE REVIEWED/APPROVED AND SIGNED BY AFFECTED <br />CITY DEPARTMENT HEADS <br /> <br />Page 6 of 10 <br /> <br />331 <br />