316640 9/29/2017 ,Cqq
""� CITY OF CARMEL, INDIANA VENDOR: 371973
® ONE CIVIC SQUARE NORTHERN MIDWEST ZNA CHECK AMOUNT: $""'""""100.00*
,? ,_�: CARMEL, INDIANA 46032 1548 TANGLEWOOD DRIVE CHECK NUMBER: 316640
ATT:RICHARD THOMAS CHECK DATE: 09/29/17
:M�*on�°�- LAFAYETTE IN 47905
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
101 5023990 GAZEBO 100.00 OTHER EXPENSES
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Lt.Jeff Horner QR-T' 4-1! -I-)(c,
CITY OF CARMEL Adam Harrington OK-
FACILITY USE REQUEST FORM
,me/Organization: _NORTHERN MIDWEST ZNA
Point of Contact: Richard Thomas
Address: _1548 Tanglewood Drive
City, State,Zip _Lafayette,IN 47905
Home Phone: (765 ) 447-3070 Cell Phone: ( 765 ) 491-3481
Email Address: rdthomas99(a),comcast.net Fax Number ( 765 ) 447-3888
For Profit Organization: Non-Profit Organization: _X Individual:
Day and Date Requested: _Thursday 9/14 through 9/17 O/ 7,
Time Requested: _9:00 a.m. to: _5:00 p.m. (This includes set-up and clean-up time.)
Rehearsal Date: _NA Time: a.m./p.m. to a.m./p.m.
City Facility Requested: Gazebo_X_ Fountain Area Japanese Garden
Palladium Center Green Caucus Room (1/3)_(2/3)_Council Chambers
Special Requests: Electricity_X_ Fountain Restroom X Other
Purpose: _KOI Show Number of People Expected: _200
Vendors: Yes (See Item 5,City of Carmel Facility Use Policy attached) _
City Street Closing: (See Item 9, City of Carmel Facility Use Policy attached)
Large or Race Events: NO
Neighborhood Street Closing(Street(s),Address(es) Blocked) NO
The Carmel Board of Public Works and Safety reserves the right, in its sole discretion, to deny
any facility use request and/or revoke any previously granted request to use a City facility for
any lawful reason.
Received this 44-11 day ofDyer,201 _.
Mayor's Office
Revised: 01/22/16