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Home My WebLink AboutSUNNY SIDE TRI telari tV`W/' i ' CITY EVENT PERMIT APPLICATION JEFFERSONVILLE PARKS DEP For events,block parties,parades,walks,runs and public rallies 500 QUARTERMASTER CT JEFF, IN 47130 812-285-6440 Return to:Jeffersonville Parks Department,500 Quartermaster Ct.,Jeffersonville Additional information contact:812-285-6440,Fax:812-285-6481 SALE EVENT NAME: Sunny Side Tri MID: 6739 Store: 0000 Term: 0002 Official name of festival or event REF#: 00000001 CONTACT/PRODUCER:Mike Purvis/Kentuckaua Race Management Batch #: 010 RRN: 903715001020 Person&/or Producer to be contacted regarding event 02/06/19 10:44:51 AB:ZIP HATCH CVC: CONTACT ADDRESS: 3028 Bobolink.Rd Louisville KY Trans ID: 309037566915249 Street City State APPR CODE: 03536G VISA Manual CNP CONTACT INFO: 502-939-6652 mike **•*********9589 Day Phone Cell Phone Fax EVENT INFORMATION AMOUNT $150.00 Event location address: Fisherman's Wharf Date: .7I:7 ./_19 Dayof week: Sunda Time: .7:30 AM Ending Date:_ APPROVED Day of week:_Sunday Time:_11:00 AM Total attendance expected: 200 THANK YOU Rain/Cancellation Policy If lightning is in the area it will be delayed 30 minutes. If it doi CUSTOMER COPY amount of time the event will be cancelled. Provide alternative dates,times and locations of event,if applicable.Must contact city coordinator ASAP if day of event. 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) BlockParty Parade_Motorcade Rally/Public Gathering_Walk/Run Other Sprint Distance Triathlon 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 tinder"Barricades" ® Provide map-showing streets to be blocked,or if a run/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/EventProducer'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 approva _'ecifications and activities described herein or failure to abide by all Federal,State and City of Jeffersonville laws, ordinances,polices and proce' es ay result in the immediate revocation of the approved permit and/or refusal toissue a permit in the futur . X / 1_1 2 /_19 r PP-11- Rl LL Vi— )4 SIGN TURF QUIRE Datept Recei # ^ / `7/444,Ailr -a 2 'oliceFire Public Works/Street Parks Safety CERTIFICATE OF INSURANCE PRINT DATE: 2/11/2019 CERTIFICATE NUMBER: 20190211686301 AGENCY: Integro USA Inc. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND d/b/a Integro Insurance Brokers CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES 2727 Paces Ferry Road,Building Two,Suite 1500 Atlanta,GA 30339 BELOW. 678-324-3300(Phone),678-324-3303(Fax) NAMED INSURED: INSURERS AFFORDING COVERAGE: USA Triathlon of Colorado Mike Purvis 5825 Delmonico Drive INSURER A:Philadelphia Indemnity Ins.Co.NAIC#: 18058 Colorado Springs CO 80919-2401 INSURER B:Philadelphia Indemnity Ins.Co.NAIC#: 18058 EVENT INFORMATION: Sunny Side Tri(7/7/2019-7/7/2019) POLICY/COVERAGE INFORMATION: 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS TYPE OF INSURANCE: POLICY NUMBER(S):I EFFECTIVE: EXPIRES: LIMITS: A GENERAL LIABILITY X Occurrence PHPK1910062 12/1/2018 12/1/2019 12:01 AM 12:01 AM GENERAL AGGREGATE(Applies Per Event) $2,000,000 X Participant Legal Liability EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES(Each Occ.) $1,000,000 MEDICAL EXPENSE(Any one person) EXCLUDED PERSONAL&ADV INJURY $1,000,000 PRODUCTS-COMP/OP AGG $2,000,000 B UMBRELLA/EXCESS LIABILITY X Occurrence PHUB655496 12/1/2018 12/1/2019 12:01 AM 12:01 AM EACH OCCURRENCE $10,000,000 AGGREGATE(Applies Per Event) $10,000,000 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS: Coverage applies to the USA Triathlon sanctioned or approved event specified on this certificate. The certificate holder is an additional insured as per form PI-AM-002:Additional Insured-Certificate Holders. The General Liability policy is primary as per Form CG0001 (04/13). The General Liability policy contains Form CG2404(05/09):Waiver of Transfer of Rights of Recovery Against Others to Us,but only as required by written contract or agreement executed by the named insured prior to an occurrence resulting in a loss or a claim. CERTIFICATE HOLDER: NOTICE OF CANCELLATION: City of Jeffersonville Should any of the above described policies be cancelled before the expiration date thereof, 500 Quartermaster Ct notice will be delivered in accordance with the policy provisions. Jeffersonville IN 47130 AUTHORIZED REPRESENTATIVE: