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HomeMy WebLinkAboutROSS BROS CARSHOW ra w4 � 13J'_ i. >.. = rCITY EVENT PERMIT APPLICATION `� �"Li For events,block parties,parades,walks,runs and public rallies (U's'�n 0 Return to:Jeffersonville Parks Department,500 Quartermaster Ct.,Jeffersonville,IN 47130 - ' '�d�� Additional information contact:812-285-6440,Fax: 812-285-6481 1-in OF gO(sl,> EVENT NAME: 9 ,O 55 'bro S `'QY 3 4 ow 't fa it= `j Official name of festival or event '" � l ^ t41�. CONTACT/PRODUCER: /ct/ /1 /t'I .9 5 x--- Person t�v`�Ls. Person&/ Producer to be contacted tegardingevent } CONTACT ADDRESS: 5X20 !4'r� 4ife 4.`e. ts-5 cl/U'/11 //11 7t5 Zip CONTACT INFO: SIg—' 8‘c",2—,5-40 81 v_9 Y6/let City 6ate" y-/u)-0,.51.117:kL®Ro2iui/ CadYi Dv Phone Cell Phone Fax E-mad EVENT INFORMATION Event location address: 5:2 O 6h i 0 1/e Date: 0 VI 01//9 Day of week: 5a fu 'c y Time: "7 OM Ending Date: 64/ a l/ / Day of week: 50 -u bora . Time: t/_ : E_M Total attendance expected: 35-o Rain/Cancellation Policy /moi C in A7 7r'e 05L(65/15. Su n dtz y 7 41W — 11 PIY1 Provide alternative dales.times andations of event,if applicable.iM st contact city coordinator ASAP if day of@vent. FEE to be paid at time of application trade payable to Jeffersonville Parks Department-SMALL llVEN $150(50 &under) (IF ATTENDANCE OVER 500 OR EVENT ENCOMPASSES MORE THAN(4)CITY FLOCKS OR MAJOR TkIOR tIMEAIE DIFFERENT EVENT APPLICATION AND FEES MAY APPLY) _Block Party Parade Motorcade_Rally/Public Gathering_Walk/Run Other Re3 G?9 ,j-©5 6—se'LA 4 41'1/CFZ't + - (W6 4E. /o — STREET CLOSINGS OR AREA TO BE USED Additional Information PIQUERED from event producer/contact: ® Notify affected business and residents of street closures e 'Provide your own barricades for all blocked 44/or street closures.Check Yellow Pages under"Barricades" e Provide map showing streets to be blocked,or if a run/walk a trap of your route o Provide a Certificate of Insurance listing the City of Jeffersonville as an additional Insured for$1,000,000 HOLD HARMLESS AND fEM1 IFICATION CL.A.1TSE 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/Everrt 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.Mist—lad Harmless and Indemnification Clause shall in no 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 specifications and activities described herein or failure to abide by all Federal,State and City of Jeffersonville laws, ordinances,polio' a proc-dures may result the im ediate revocation of the approved permit and/or refusal to issue a permit in the fllture. f� 0.2/ / / / 23 SIG,ATURE REQUIR t r Date ®/ 'cccipt fl '',/ &icy- ` lt^,C�.�' ,iv' ,Q�1 � ► /�a l- / ,� / 2 - �'!/1 L r '4-r.ce / Fire Publ c'Works/Street Parks afory APk-n-1U16 IUt U6: bi AM CALLISIUS SMI111 AbENUY I-AX No. tlI 'L4NU'L61 r• UUC vc��IN ...--'—'""N ROSSB-1 OP ID;AW Ati CERTIFICATE OF LIABILITY INSURANCE Dar /02/2018 04/0212018 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 en ADDITIONAL INSURED, the pollcy(les)must have ADDITIONAL INSURED provisions or 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(SL PRODUCER 812-944-7711 ACT Brian C Smith P&C — Calllstus Smith Agency,Inc, (Hq 812.944-7711 FAX NoAX I No):812-945-0281 3415 Paoli Pike A1C,NNo,Ext): Floyds Knobs,IN 47119 Brian C Smith P&C SS: INSURERS)APFORDINO COVERAGE NAIL p INSURED Ross Bros Automatic INSu R A;Stat©Auto Insurance Co 25135 Transmission Service,Inc. INSURER e 520 Ohio Ave INSURERS,..; Jeffersonville,IN 47130 INSURER D: INSURER E; • INSURER F; OVERAGES CE IFICATE 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 •ooL VeR POLICY EFP POLICY EXP 7; TYPE OF INSURANCE • A • POLICY NUMBER ,I,•••IMI I I/•••111/1 LIMITS A © COMMERCIAL GENERAL LIABILITY EACH QCCURRENCE $ 1,000,000 ■■CLAIMS-MADE I "1 OCCUR BOP2620547 06/30/2017 06/30/2018 DAMAGE TO RENTED 300000 11111 pREMI6ES(CLQGClrr@OCEI if MED EXP(Any one person) 10,000 PERSONAL&ADV INJU$Y S 1,000,000 GEN'LAGGR° LIMIT APgpOR: GENERA,AGGREGATE 2,000,000 POLICY I I j T I 1 LOC PROQUCTS-COMP/OPAGG $_ 2,000,000 U • R: $ A AUTOMOBILE LIA01LIiYOMBINED SINGLE LIMIT 1,000,000 EA ErCldenl) € igi ANYAUTO BAP2327251 08/30/2017 08/30/2018 BODILY INJURY(Per_,ereon) ,$ II OWNED MN SCHEDULED AUTOS ONLY AUTOS BODILY INJURY S : q�p pN pV� PPR � 1 L NI AUTOS ONLY II AUTOS ONLDY ra FaTATnliAMAGE $ _ R A UPAOR LLA UAB li OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LISA 111 CLAIMS-MADE CXS2101534 06/30/2017 06/30(2018 AGGREGATE $ DED RETENTION S L WORKERS COMPENSATIONI PER DTH- AND EMPLOYERS'LIAEII.ITY STATIITP ER QANYCCPROPRIIETO�R�/PARTNER/EXECUTIVE YIN ( f4Ni ry in NH)EXCLUDED? NIA ,L.EACH ACCIDENT If ygg,degcrlbe under ' E.L,DISEASE•EA FM�'LOYEE $ DE RIPYI• • OPERATI.N Iercw E.L.DIRFASE-POLICY LIMIT 5 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101,Additional RaMerke Schedule,may be altachod If more epaca is required) Certificate Holder is named as aditionai insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION OATS THEREOF, NOTICE WILL BE DELIVERED IN City of Jeffersonville ACCORDANCE WITH THE POLICY PROVISIONS. City-County Ruliding Jeffersonville, IN AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 AGORA CORPORATION, All rights reserved. The ACORD name and logo are registered marks of ACORD