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2. Name
3. Phone Number
5. Address
7. City
8. State
9. Zip Code
11. Street/Streets
13. Address to Address
14. Date
    Date
15. Time to Time
    Time to Time Start Time

    —

    Time to Time End Time
17. Purpose
19. Signature of Applicant

    The undersigned person is responsible to see that upon completion of the activity or use of the area, the area must be cleaned up and restored to a presentable appearance. The undersigned person is also responsible for notification of news media of the dates, time and purpose of the street closing. The undersigned person requesting the use of this street is also responsible for contacting and receiving permission from owners of adjacent properties, concerning the use of the property adjoining the street.
    
    By checking this box, I authorize my signature.

    1. Check Here
21. Date of Application
    Date of Application
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24. Print Only

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