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1 <br />Special Event Permit Application <br />I. Title and Brief Description of Event <br />______________________________________________________________________________ <br />______________________________________________________________________________ <br />II. Applicant Information <br />The applicant is responsible for answering all questions, including inquiries from media and <br />citizens. <br />Applicant:___________________________________ Title:_____________________________ <br />Address:_______________________________________________________________________ <br />Business/Organization:___________________________________________________________ <br />Daytime Phone:____________ Mobile Phone:_____________ Emergency Phone:____________ <br />III. Event Timetable <br />A. Requested day and date:__ _________________________ <br />B. Requested Hours of Operation, from __________a.m./p.m. to ____________a.m./p.m. <br />C. Set up beginning day and date , time ______________a.m./p.m. <br />D. Dismantle by day and date_ __, time ______________a.m./p.m. <br />E. Anticipated number of participants: ______________; and spectators: ______________ <br />IV. Insurance <br />Attach to this application either an insurance policy or a certificate of insurance including the policy <br />number and showing liability amounts. The policy must state that any outside area to be used for <br />an event is covered. The policy must also show evidence that the requested event is not excluded <br />from insurance liability. <br />Lake Elmo National Night Out - Block party style event for city <br />Molly Brendmoen Resident <br />3631 Laverne Ave North Lake Elmo, MN 55042 <br />Lake Elmo Night Out Planner/Organizer <br />651-338-3410 <br />4 pm 9pm <br />4:30 pm <br />9pm <br />Event is 6pm-8pm <br />500 Total amount