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CITY OF DOUGLAS 24-HOUR ADDITIONAL DISPENSING ROOM PERMIT APPLICATION INFORMATION REGARDING APPLICANT: Full Name: Name of Organization: Address: City: Contact person: INFORMATION REGARDING EVENT: Type of event to be held: Premise where permit will be used: Location in building where permit will be used (explain in detail and attach diagram if necessary: Date permit will be used: Hours permit will be used: to Number of people attending (estimate): Any person, organization, or licensee who is issued a permit hereunder, shall by operation of the issuance of the permit, indemnify and hold the City, its employees, agents and representatives, including members of the City Council in their representative capacities, harmless from any liability, loss or damage which may be incurred as a result of claims, demands, costs, or judgments arising out of, connected with, or concerning the issuance, use or existence of the permit. SIGNATURE OF APPLICANT DATE OF APPLICATION ∞ ∞ ∞ ∞ ∞ ∞ ∞ ∞ ∞ ∞ ∞ ∞ ∞ ∞ ∞ ∞ ∞ ∞ ∞ ∞ ∞ ∞ ∞ ∞ ∞ ∞ TO BE COMPLETED BY CITY CLERK Permit Fee Receipt # Date of Approval License # issued Date Received Date of Council Approval ---PAGE BREAK--- ****STAFF COMMENTS**** CITY ADMINISTRATOR ADMINISTRATIVE SERVICES DIRECTOR CITY CLERK CHIEF OF POLICE PUBLIC WORKS DIRECTOR COMMUNITY DEVELOPMENT/PLANNING DIRECTOR