Form 41 - Facility Use Page 2

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Lake Stevens Fire Administration Use Only
*********************************
Reviewed & Posted by:_______________________________________________________________________________
Additional Notes: ___________________________________________________________________________________
__________________________________________________________________________________________________
Alcohol Permit
(Yes) (N/A)
Certificate of Insurance
(Yes) (N/A)
Rental Fee
(Yes) (N/A)
Amount $ ____________________
Additional Fees / Schedule Service Appt
(Yes) (N/A)
Amount $ ____________________
Email Confirmation Sent
(Yes)
Total
$ _____________________
Posted on Conference Center Tracking
(Yes) (N/A)

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