2. This application must be completed, signed, and forwarded to the Jefferson County Administrator at least 90 days prior to the first day of the event. Any misrepresentation in this application, or deviation from the final agreed upon route and/or method of operation described herein, may result in the immediate revocation of the permit. Please type or print information clearly and attach additional sheets as necessary.
4. Event
6. Event Type

   1. Exhibition (EX)
   2. Parade (PA)
   3. Dance (DA)
   4. Race (RA)
   5. Walk (WA)
   6. Drama (DR)

   1. Ride (RI)
   2. Festival (FE)
   3. Musical Event (ME)
   4. Run (RU)
   5. Other (OT, please specify)

   (Check 1)
8. Other (Event Type)
   If you selected other as the event type, please specify the type and be specific.
10. Event Date
11. Day(s) of the Week
12. Time(s)
13. Event Location
15. Facilities to Be Used

    1. Park
    2. Street
    3. Sidewalk
    4. Private Property
17. Set Up Times
    Set Up Times

    Set Up Times
18. Dismantle Times
    Dismantle Times

    Dismantle Times
20. Purpose of Event
22. Event Crowd Size
24. Participants
25. Spectators
26. Volunteers/Personnel
28. Has this event been produced previously?

    1. Yes (specify dates)
    2. No
29. If this event was held before, what were the dates.
31. Any change from previous events? (Yes or no)
    If yes, list changes for this year’s request.
35. Applicant Information
37. Event Name
39. Organization Name
40. Phone Number
42. Mailing Address
44. City
45. State
46. Zip Code
48. Applicant's Name
49. Title
50. Phone Number
52. Contact Person
53. Title
54. Phone Number
58. Exemption Request
60. Are you requesting exemption from the special event fees?

    1. Yes
    2. No
61. State the reason for the exemption (e.g. constitutionally protected, etc.)
65. Fees and Proceeds
67. Admission Fee

    1. Yes
    2. No

    (Check 1)
68. Fee Details
    If there is to be an admission fee, how much?
70. Vending or Sales

    1. None
    2. Food
    3. Books
    4. Beverage

    1. Balloons
    2. T-Shirts/Hats
    3. Button
    4. Other (please specify)
72. Additional Vending or Sales
    Please specify any additional vending or sales options at your event.
76. Entertainment and Promotions
78. Sound System

    1. Acoustic
    2. Amplified
79. Describe Entertainment
81. List of Entertainers or Bands Performing at Event:
83. Check Type of Promotion You Plan to Use to Attract Participants:

    1. TV
    2. Radio
    3. Newspaper
    4. Billboards
    5. Posters
    6. Flyers
    7. Social Media
    8. Other (please specify)
85. Please Specify Any Additional Promotion Not Already Listed
87. Have local neighborhood groups or businesses approved your event concept?

    1. Yes
    2. No
88. If local neighborhood groups or businesses have not approved your event concept, what steps will be taken to notify them of your event?
90. List Community Contacts and Phone Numbers (for Verification)
92. Name
93. Phone Number
95. Name
96. Phone Number
98. Attach an Approval Letter
102. Special Set-Ups Requested
     Describe various categories and fill in details on numbers, size and type. Leave blank if not applicable.
104. Animals
105. How many
106. Species
108. Booths
109. How many
110. Where
112. Commercial Signs
113. How many
114. Size
116. Electricity Signs
117. Generators
118. How many
120. Fireworks
121. Ground
122. Aerial
123. Fireworks Company
125. Portable Restrooms
126. How many
127. Handicapped accessible
129. Rides
130. How many
131. Type
133. Staging/Scaffolding
134. How many
135. Height
137. Tents/Canopies
138. How many
139. Size
141. Vehicles
142. How many
143. Type
145. Water
146. Potable
147. Non-potable
149. Noise Variance

     1. Yes (If yes, $100 permit fee required)
     2. No
150. Basis for Variance Request and Hours
154. Public Safety
156. Site and/or Route Map
     Attach a clear, legible site and/or route map with the following indicated: - North, indicated by directional arrow - Names of streets with one-way streets marked - Number and placement of barricades - Any other details you think will be helpful
158. What are your plans for on-site security, monitors, and route control?
159. What are your plans for medical assistance?
161. Discuss your parking plans for participants and spectators:
163. List any additional information which the Special Event Committee may find reasonably necessary for a fair determination of whether a permit should be issued.
167. Insurance Information
169. Name of Insurance Agent
171. Address
173. City
174. State
175. Zip Code
177. Phone Number
178. Name of Contact Person
180. Name of Insurance Company
181. Policy Number
183. Will liquor be served at this event?

     1. Yes
     2. No
187. Garbage and Recycling
189. Are you providing garbage and recycling containers?

     1. Yes (please describe)
     2. No
190. If you will provide garbage and recycling containers, please describe.
194. Traffic Control Plan
196. Police officers are required at all signalized intersections. Flaggers are required at all non-signalized intersections. Monitors may be required at driveway entrances and other pedestrian and vehicle access points.
198. Traffic Control
     (specify if monitor, flagger, or police officer)
199. Location
200. Duties
202. Traffic Control
     (specify if monitor, flagger, or police officer)
203. Location
204. Duties
206. Traffic Control
     (specify if monitor, flagger, or police officer)
207. Location
208. Duties
210. Print Applicant's Name
211. Today's Date
     Today's Date
212. Applicant's Signature
Leave This Blank:


214. 1. Receive an email copy of this form.
215. Email address

     This field is not part of the form submission.

216. Submit

* indicates a required field