City of Covington EVENT PERMIT APPLICATION EVENTS ON CITY OWNED PROPERTY

Transcription

1 Received By: PLEASE CHECK ONE OF THE FOLLOWING: Permit No.: This event is Specil Event defined s temporry community interest event, open to the generl public. For exmple; musement, recretionl, entertinment or community interest ctivities such s but not limited to crnivls, rodeos, horse shows, shooting events, thletic events, rt shows nd community firs. This event is Privte Event tht is not open to the generl public. I. APPLICANT INFORMATION: Applicnt: Contct Nme: Phone: Dte Received: Applicnt Address: Emil Address: II. LOCATION OF EVENT: Address: Hs lese greement with the City been executed? Yes No. III. EVENT INFORMATION: Dtes of event: From To Time: Number of people expected to prticipte in the event: Plese describe the event: Which of the following menities will be necessry to fcilitte the event: Electricl service; Plumbing service; Wter or Sewer service; HVAC service; Port-John Dumpster service; Other plese describe: If mplifiction equipment will be used, plese see the ttched City Ordinnce Section If lcohol is being served; cterers nd pouring licenses re required. If tent is erected, n inspection by the Building Inspector nd Fire Mrshll is required. If food is prepred nd/or served, food service permit from the Deprtment of Helth is required. Food service permits re not required for privte events. Plese ttch copy of ll invittions, flyers, tickets, etc. to this ppliction if it is Specil Event. 1 of 5

2 IV. CERTIFICATION: I, the pplicnt, red nd understnd the contents of this ppliction. I certify tht tht the informtion contined herein, including ttchments nd ll other supporting informtion, is complete nd true, to the best of my knowledge. I further gree tht to sve, indemnify, nd keep hrmless the City of Covington, its officers, employees, nd gents ginst ll libilities, judgments, costs, nd expenses which my ccrue ginst them in consequence of the grnting of this permit, inspections, or use of ny on-site or off-site improvements plced by virtue hereof, nd will in ll things strictly comply with ll pplicble rules nd ordinnces. Signture constitutes n ttesttion by the owner or owner s uthorized representtive(s) tht ppliction complies with ll covennts, conditions, nd restrictions. Signture of owner/pplicnt or representtive: Dte: 2 of 5

3 V. AFFIDAVIT VERIFYING STATUS FOR CITY PUBLIC BENEFIT APPLICATION I, m pplying to the City of Covington, Georgi for n (Nme) Event Permit on City of Covington Property. I hereby stte, under oth, with respect to my ppliction for (Nme of business, corportion, prtnership, or other privte entity) tht: 1) I m United Sttes citizen or legl permnent resident OR 2) I m n otherwise qulified lien or non-immigrnt under the Federl Immigrtion nd Ntionlity Act, 18 yer of ge or older, lwfully present in the United Sttes. * In mking the bove representtion under oth, I understnd tht ny person who knowingly nd willfully mkes flse, fictitious, or frudulent sttement or representtion in n ffidvit shll be guilty of violtion of Code Section of the Officil Code of Georgi. Signture of Applicnt Dte Printed Nme Alien Registrtion Number for Non-Citizens* NOTARY SEAL: Sworn to nd subscribed before me on this dy of,20 Notry Public My Commission Expires: *Note: O.C.G.A (e) (2) requires tht liens under the Federl Immigrtion nd Ntionlity Act, Title 8 U.S.C., s mended, provide their lien registrtion number, becuse legl permnent residents re included in the federl definition of lien, legl permnent residents must lso provide their lien registrtion numbers. Qulified liens tht do not hve n lien registrtion number my supply nother identifying number below: 3 of 5

4 ** FOR OFFICIAL USE ONLY ** Distribution for review: Plnning Director Fire Mrshll Building Inspector Public Works Deprtment Police Deprtment Trnsporttion Deprtment Utility Deprtment PLANNING AND ZONING Approved: Denied: Approved with remrks If issued, the Applicnt must present this Permit, upon request, t ll times during the event. Plnning Director s Signture: Dte: Covington Police Chief s Signture: Dte: 4 of 5

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