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H ENNEPI N COUNTY SII-IIIEII E FFS 3FFffC E <br />WATER PATROL UMT <br />1 r°r r •� r r r r r -r r�° r r gr r •� r rv� <br />The permit cannot be issued without the below items: <br />Written permission is required from the city or cities in which this event is to be held. <br />The insurance certificate must show Hennepin County as an additional insured. —j <br />The following information is necessary to insure the proper and accurate issuance of your permit. <br />Please complete this form in its entirety and return the original form to our office at 4141 Shoreline <br />Drive, Spring Park, MN 55384, at least thirty (39)Slays prior to your event. (Faxed/scanned copies <br />of the liability release and this application are not acceptable.) <br />Please PRINT or TYPE <br />NAME OF EVENT: C de? 1�-111a'112 W4'e- r0v"e .CSE -, '7 <br />DATE(S) OF EVENT: O �L'+ ---'o <br />TIME(S) OF EVENT: M ov, �� � � V�1 4� Aww 1 3 �" S" s � a" d a �< �- <br />3 e Vtn � �®�.� �,��� y� C ec ' f tet' <br />EVENT LOCATION: (A diagram should be included for larger events.) et <br />Specific at& include start & finish locations <br />WAS THIS EVENT HELD LAST YEAR: YES 'K NO <br />SPONSORING ORGANIZATION: L FAfj L,2 ,2o ° � r{ <br />CONTACT PERSON: An'y Jz� 1 <br />DOB: '/ �l l "�- DL#: LL <br />ADDRESS: f"® 00K Sq a —L � S S � ?' <br />PHONE: <br />Street Address <br />6D S(50 I M 2- <br />Home <br />Work <br />City <br />Cell <br />E-MAIL ADDRESS: `O ^g a = "a%-V'M!2r 0. � % e <br />1-0 <br />State Llp <br />Fax <br />EVENT WEB ADDRESS: VV L <br />PROPOSED EVENT ACTIVITIES: 4� r 'gym :I � 0 <br />