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R,OSEVILLE,AREA SCHOOLS <br />DATE APPLICATION l�LfUs� <br />IndependentSchoolDiathiet No:�623 <br />Fairview Community, School Center <br />COPY T0: <br />�; 1910 West County Road B+k <br />„Rose.vi ie,.Minnesota' 55113 <br />% Custodian - White r ' <br />�4 <br />PHONE :r`633=gl5O,,ext. 311 <br />Building Administrator Gold <br />L Building Supervisor Canary <br />L% Organization Green: <br />' COMMUNITY S VIOES BUILDING USE PERMIT <br />" <br />Lam. Community Education Office Pinky <br />School fps: 11 i 1 Area Ff _i qll aE:hoo i <br />' <br />Facility:- Hilt it r"'`fl,il11: <br />F4'r3 <br />Additional Information 5jI` <br />Activity will beg in'`at ��'00P1`fend' at l�IdniCi�it <br />Time Time <br />yr <br />GrPN <br />oup desires to enter building at <br />Time <br />W F S S <br />Days Desired: T TH <br />.,;Ug <br />_ 1�tl�t�St, 3. � August <br />Dates: <br />Approximate Number 'of People Expected - <br />Certificate of Insurance Required Yes No <br />31 <br />Amop+nt of Insurance Required <br />W <br />I ty d " R0Si:'Vi <br />ORGANItAi ION <br />Person Responsible Richard ` OPI(i� Phone <br />490 -M6 <br />Business Home <br />20,60 Ci Vi C ;enter Dy i ve , kusev I I e <br />filN 5d113 b5113 <br />Address <br />r Were Permit to be Sent <br />4 1i <br />Zip Code <br />,is <br />L �i` Y P�fc�nning conil�i SSioll <br /><: Specific Activity, <br />- <br />ESTIMATED FEES: ,(A final billing of all charges EQUIPMENT NEEDS: <br />will be made after completion ofevent) <br />W .; RENTAL t`!G ... ; . ... . - .-, <br />PHYSICAL. EDUCATION . .. .. a. . <br />CUSTODIAL $16.501, Jr". if necessary <br />COOK <br />AUDIO VISUAL <br />BLDG. SUPERVISOR 5OI'fr". (appr"oxifne -cly 2 fours) <br />POOL <br />OTHER Air GO.iC�"i �i On 1 11 a tab! c/c+Frt l rJr okl r <br />a '-� i �:�'rrl'i cul �1ici 5/rir. <br />��iage for E 1., i r cr�op�iotes <br />OTHER . <br />A l"O+,,i 55s Lo acC:o6i moda'Ge cable <br />�approxiinate'iy 22 rlt"s. is ; .LU/;lr . <br />We -agree to abide by the regulations ,as printed on the back of -this <br />perm f <br />u orii�"S'igria'ture'RepreerntingOrga�ization <br />Community School S rvices Director or Delegated Agentx <br />APPROVED SICGNED PERMIT MUST BE ON, FILE BEFORE CROUP' WILL BE ALE TO USE FACILITY , <br />Rov.. iss <br />o� <br />7� n y <br />