2005-07-27 CC Packet - Laserfiche WebLink

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, Centerville Special Event Permit Application TITLE, PURPOSE, AND BRIEF DESCRIPTION OF EVENT: t1~ ~;~JU(.J 1. New Application: -/ Renewal of or Change in Application: CONTACT PERSON: (:(cJU c7("a... /71 ~ TELEPHONE: ~~/- ,/(2.q- ~3/.6 (~) OR " 2. IDENTIFYING INFORMATION: Attach a written communication from the organization(s) in whose name the event will be advertised which authorizes you, the applicant, to apply for this special event permit on its/their behalf. Applicant'sName:~~o1-~ Title: h~ a~ Address: Mailing Address: % 7087 ~"IW / r!vn;t-f.NIIdt.. 6'Soi3/i' Affiliation: ~ Day Phone: 1,,5/-1"0<.'1- 8"3 It" Evening Phone: ~ Emergency Phone: 3. EVENT PRINCIPALS: Following, please list the names, addresses and telephone numbers of all the principals involved in any of the proposed special event. Include professional event organizers, event promoters, fmancial underwriters, commercial sponsors, charitable agencies for whose benefit the event is being produced, the organization(s) in whose name the event is being advertised, and all others administratively, financially and organizationally involved as principals in the production of the proposed special event. Make additional copies ofthe following as needed to include as of the principals involved in the proposed special event. Name: 01 ~/V0' d~ Organization/Business! Agency/Affiliation: Is this a non-profit organization? V Yes No If you are making application under non-profit status, proof of non-profit status must be attached to this apJ'lication Mailing Address: 7og7 (')lx.~7L -Pel ('vn~x;J4.. Day Phone: {f~/- l/,;z "i - 7? 57 t Evening Phone: Ti~~m~reg~~ . ~-' - y ~ Page 1 of 10 ~.-' 35:,