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HomeMy WebLinkAboutCHILDREN'S NETWORK CAR SHOW "►. G�T3'i0 s� t � � CITY EVENT PERMIT APPLICATION Forev<nts,blockpartia,paradcs,walks,mns and public rallies with a maximum attendance under 50opcuple Pv1 Return to:Jeffersonville Parks Department,500 Quartermaster Ct.,Jeffersonville,IN 47130 Additional information contact: 812-2f85-6/440,F�ax/:8.1122-285-6481 n EVENT NAME: C:tnrl, ,70 , mac-, 1`-t,yt-�''t-d e ! �f ZJD� (,,g dt-: 0[ficialnameoCfestivalurevent CONTACT/PRODUCER: j J 1 LL ( cllj�erS Person 8:ur Ptoducer 1<be contacted regarding event CONTACT ADDRESS: 2,1 2-3 Stmet City Sul. CONTACT INFO: YF- S,7 4G!K Aol,� e 2,5, ,M-7),C-0'Y a� Day Plum. Cell Phune Fax E-mail EVENT INFORMATION /`,L Event location address: JI" Starting Day; Date: / Ls�/t Time: 9 : 3o _M Ending Date: / fs`/ /;Time: Z :?Q-M Total attendance expected: ZD 0 Rain/Cancellation Policy fZ f ..Su.,v Provide alternative dates,times snd locad<ns of evens,it ap cable.Mast cumaa city eourdinaturASAP irday of went. FEE to be paid at time of application made payable to Jeffersonville Parks Department—SMALL EVENT$150(500&under) (IF ATTENDANCE OVER 500 OR EVENT ENCOMPASSES MORE THAN(4)CITY BLOCKS OR MAJOR THOROUGHFARE DIFFERENT EVENT APPLICATION AND FEES MAY APPLY) _Block Party_Parade_1�otorcade_Rally/Public Gathering_Walk/Run Other CVL S" --, STREET CLOSINGS OR AREA TO BE USED Additional Information REQUIRED from event producer/contact: • Notify affected business and residents of street closures • Provide your own barricades for all blocked&/or street closures.Check Yellow Pages under"Barricades" • Provide map showing streets to be blocked,or if a nm/walk a map of your route • Provide a Certificate of Insurance listing the City of Jeffersonville as an additional Insured for$1,000,000 HOLD HARMLESS AND IDEMNIFICATION CLAUSE The applicant/Event Producer shall indemnify,hold harmless and defend the City of Jeffersonville and the Jeffersonville Parks&Recreation Department,their elected and appointed officials,employees,agents and successors in interest from all claims,damages,losses and expenses including attorneys'fees,arising out of or resulting,directly or indirectly,from the Applicant/Event Producer's(or Applicant/Event Producer's subcontractors,if any)performance or breach of the contract provided that such claim,damage,loss of expenses is:(1)attributable to personal injury, bodily injury,sickness,death,or to injury or destruction of property,including the loss of use resulting there from,or breach of contract,and(2)not caused by the negligent act or omission or willful misconduct of the City of Jeffersonville or the Jeffersonville Parks&Recreation Department,their elected and appointed officials and employees acting within the scope of their employment.This Hold Harmless and Indemnification Clause shall in no way be limited by any financial responsibility or insurance requirements and shall survive the termination of the Small Event Permit Application. Only applicants in good standing with the City of Jeffersonville will be considered for Approval.Any misrepresentation in this application or deviation from the final approval specfiis. 'ons and activities described herein or failure to abide by all Federal,State and City of Jeffersonville laws, ordi anc cies and procedures resu in the immediate revocation of the approved permit and/or refusal to issue a permit in the future. SIGNATURE REQUIRED �L LL (7 J� sS Date Receipt At Police Fire Public orks/Street Pars Safety r f�� i — REMAX-3 OP ID: TS ��C7Ro CERTIFICATE OF LIABILITY INSURANCE FDA07/13/2017Y) 07/13/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Brian C Smith Callistus Smith Agency,Inc. NAME:PHONE FAX 3415 Paoli Pike ac No EXt:812-944-7711 AIC No:812-945-0281 Floyds Knobs,IN 47119 E-MAIL Brian C Smith P&C ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:West Bend Mutual Ins Co 15350 INSURED Childrens Miracle Network INSURER B: Car Show/ReMax First 2123 Veterans Pkwy INSURERC: Jeffersonville, IN 47130 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DOL POLICY EFF POLICY EXP LIMITS LTR IN D WVD POLICY NUMBER MMIDD MMIDD A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,00 DAMAGE TO RENTE CLAIMS-MADE a OCCUR X BINDER 07/15/2017 07/16/2017 PREMISES Eaoccurrence $ 100,00 MED EXP(Any one person) $ exclude PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 X POLICY ] PRO JECT F—] LOC PRODUCTS-COMP/OP AGG $ OTHER. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER TH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more Space IS required) Event: Childrens Miracle Network Hospitals Car Show/Motor Cycle Run Sponsored by Re/Max First July 15,2017 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Jeffersonville Parks Depart ACCORDANCE WITH THE POLICY PROVISIONS. 500 Quartermaster Court Jeffersonville, IN 47130 AUTHORIZED REPRESENTATIVE '4- P '-/� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD