2005-07-13 CC Packet - Laserfiche WebLink

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( ;j51-~53-/P33 t!-t!/J-/erv/I/e.- ~,;/tJns tervi[[e 'Es/afJtw;..;,'t!1S57 Centerville Special Event Permit Application 1. /' Renewal of or Change in Application: New Application: CONTACT PERSON: Rob ~ f' I /fa- "H1o I.JJI1 I! lELEPHONE: "Sf '1 ;;Z'1 - q (') oz- 7 OR I 2. IDENTIFYING INFORMATION: (om Attach a written communication from the orgaoization(s) in whose name the event will be advertised which authorizes you, the applicant, to apply for this special event permit on itsltheir behalf. Applicant's Name: fkr-l- ~~d.uJ.a.y, Title: ~:;~~p-G Address: 1/)1,0 d &ontv,j f.'our"'I-) (J~nh/J/; //~, ~AI t:23. Mailing Address: '~l1h(~C~~t ~ Affiliation: 11)/1./-1<<. I, <J"#.bnd. /I.Ad.flkr; IS'; (!,.I//L/J'Y i"J',,;"" A"",,,,,,e. Day Phone: tA?i-"I.t'l-']tJZ7 Evening Phone: 1..5l-4-l.9-9~^"7 Emergency Phone: t.5/ --12 9- 9/)2'7 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, financial underwriters, commercial sponsors, charitable agencies for whose benefit the event is being produced, the orgaoization(s) in whose name the event is being advertised, and all others administratively, financially and orgaoizationally involved as principals in the production of the proposed special event. Make additional copies of the following as needed to include as of the principals involved in the proposed special event. Name: .:5tLlYle. 11 '" ri J./l ve. Organization/Business/ Agency/Affiliation: Is this a non-profit organization? Yes No viA If you are making application under non-profit statos, proof of non-orofit status must be attached to this aoolication Mailing Address: Day Phone: Evening Phone: Title and functional responsibility with regard to the event: ( Page I oflO 53e ,c.s" .5 /L<;t .5; d r '7 ~ p&..u ? LAfo~ L