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r Lake Mlnnjtor.Ua Conservation DistrictWinter .-j * f”* . i ' tf.* /• <br />Special Event License Application r '^iCi m <br />Page 3 lEv^t) <br />16. Public liability insurance: Coverage ^00^1 f./j f) IHK'fr\ ^ <br />Coro p a n ~-^t)dtO ^t17. Hennepin County Sheriff's Water Patrol requires your Application. A copy la <br />enclosed. <br />18. Other agencleo may olso require your afpllcatlons and their <br />MN DNR (772-7950), clty/clties, and Hennepin Parks (Guest Services, 559-67207. <br />19. r E E S. Please note: this fee is for processing of the application and does not <br />entitle the applicant to a license or refund. <br />BASE FEE, Includes events up to days <br />^days over 4 0 SlO/day <br />Sub Total. . . . . . . . . . . . . . . . . . <br />LATE PENALTY, applies to NEW events submitted less than 60 <br />prior to the event, and applies to RENEWALS submitted .ess <br />than 30 days prior to the event. . . . . . . . . . . . . . . . . . . . <br />$ <br />•f <br />$ <br />1 0 0 <br />r-0 "tr- <br />PLUS <br />LICENSE DEPOSIT, refundable, depending upon full compliance with the <br />LMCD Code and extent of admialstraclve, inspection and legsl <br />service required. . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br />1 0 0 <br />TOTAL fEE attached <br />I certify thet the information provided herein and the DUtrlH <br />and Lrrict. I understand that any license grented may be revoked by t^ District <br />ana correct. » , i aetee to reimburse the District for any <br />•ndEH;”::; ;;v;; <br />and agents of the District et ell reasonable " <br />whether or not the Code of the District Is being compileddl-h. <br />Authorised alart»a.ure 'Ah(M rxsvft <br />Please return this appllcetlon <br />and attachsenti toi <br />Title <br />Lake Hlnnetoeiia Cemserval lem bislrlct <br />too 1. wavtata ilvd.. fmlte IbO <br />klaysata. Hinnesota 553V1 <br />PHeme. (612» A7J-7013 <br />«m#ei