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2. Application Fee
   An $11 application fee is due with the application.
4. Today's Date
   Today's Date
6. Applicant Name
7. Phone
9. Applicant Address
11. City
12. State
13. Zip
15. Preferred Block Party Date
    Preferred Block Party Date
16. Alternate Block Party Date
    Alternate Block Party Date
18. Start Time
    Start Time
19. Finish Time
    Finish Time
21. Approximate Number of Attendees
23. Purpose of Block Party
25. Specific Location
    List street(s) to be closed and any other explanatory information.
27. Agreement
    Signature of Applicant implies express agreement in compliance with all laws. Applicant shall provide for the collection and removal of all trash, garbage, and litter caused by or arising out of the block party. The city may impose a service fee for any clean-up costs incurred by the city as a result of the block party. Applicant agrees to hold the City of Xenia, its employees, agents, servants, boards and commissions harmless from liability arising from the issuance of the block party permit and from the conduct of the participants of the block party. Applicant indemnifies the City of Xenia, its employees, agents, servants, boards and commissions against all claims of injury or damage to persons or property caused by the negligent acts of the applicant.
    
    Applicant agrees that he/she is the primary contact person in charge of block party; and, at the time application is made, Applicant has submitted a petition bearing the signatures of sixty percent (60%) of the property owners and/or tenants, or building managers whose property adjoins the public street being closed. Provided the Applicant has demonstrated a good faith effort in obtaining signatures, a petition with less than the required signatures may be accepted.
29. Digital Signature*
31. Please see City of Xenia Codified Ordinance #412.10 for additional information.
    City of Xenia Codified Ordinance #412.10
35. Signatures & Property Addresses
    List property owners and/or tenants or building managers whose property adjoins the property street being closed need to sign to signify their approval (be sure to list address).
37. Property Owners, Tenant or Building Manager
38. Address
40. Property Owners, Tenant or Building Manager
41. Address
43. Property Owners, Tenant or Building Manager
44. Address
46. Property Owners, Tenant or Building Manager
47. Address
49. Property Owners, Tenant or Building Manager
50. Address
52. Property Owners, Tenant or Building Manager
53. Address
55. Property Owners, Tenant or Building Manager
56. Address
58. Property Owners, Tenant or Building Manager
59. Address
61. Property Owners, Tenant or Building Manager
62. Address
64. Property Owners, Tenant or Building Manager
65. Address
67. Property Owners, Tenant or Building Manager
68. Address
70. Property Owners, Tenant or Building Manager
71. Address
82. This permit has been issued in accordance with Section #412.10 of the Xenia Codified Ordinances subject to revocation or suspension for cause and is not transferable. Applicant shall provide for the collection and removal of all trash, garbage, and litter caused by or arising out of the block party. The city may impose a service fee for any clean-up costs incurred by the city as a result of the block party.
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85. 1. Receive an email copy of this form.
86. Email address

    This field is not part of the form submission.

87. Submit

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