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2. Name of Business*
4. Street Address*
5. City, State, and Zip Code*
7. Applicant Name*
8. Telephone Number*
10. Cell Phone Number
11. Email Address*
13. Date and Time of Activity*
    Date and Time of Activity

    Date and Time of Activity
15. Description of Proposed Activity*
17. Location or Route of Activity*
19. Diagram or Map*
21. List Equipment to be Used*
23. Describe Plans for Traffic Control*
25. Police Assistance Required?*

    1. Yes
    2. No
27. Describe Plans for Debris Cleanup (if any)*
29. Applicant Signature*
30. Printed Name
32. Title*
33. Date*
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit Submit and Print

* indicates a required field