No preview available
HomeMy WebLinkAboutLEADERSHIP SI DOGS HELPING HERO'S - GXr Y pa,V .'S� -44-WO-. 60i.;01 4) APPLICATION , �o CITY EVENT PERMIT1 For events,block parties,parades,walks,runs and public rallies i,..,.,,,114.-. Return to:Jeffersonville Parks Department,500 Quartermaster Ct.,Jeffersonville,IN 47130 Additional information contact:812-285-6440,Fax: 812-285-6481 ‘'"4. ��1('r• EVENT NAME: _'/Ll 4 f� 0 heist name of estiva or event } CONTACT/PRODUCER: J(a-�-iher-i- nt Applicant df:Joir Prodacet fanner to bit contacted regardrng n� I �� � CONTACT ADDRESS: I C.24 L1't�LS 4—(l'lGil�,L''l�t tJ Ia f/l e Zip City State Street -1 CONTACT INFO:UIo1,. 63--07: )--- „55 -.6-47Q-'7010Fax [:mar. Day Phone Cell Phone EVENT INFORMATION . Event location address: t G lath 1'/On M Ending Date: ID( / Dj 61 Date: D4 / Ia / Day of week? ---rh''r', Oj_4 Time: Day of week: 4-5i'0L) Thy(e: :/1r°� � jt M ^� P'M VO Total attendance expected: / L�� ^I Rain/Cancellation Policy k ('n vIrr9.//a-1-/'n r, f Ale 34 Provide alternative dates,times and locations of event,if applicable.Must contact city coordinator ASAP if day of event. partment—SMALL NT 5150 000& FEE to be paidDAN at time application0ORNT de payable to Jeffersonville Parks ENCOMPASSES MORE THAN(4 CT Y BLOCKS OR MAJOR THOROUGHFARE under) (IF ATTENDANCE OVER 500 OR EVE DIFFERENT EVENT APPLICATION AND FEES MAY APPLY) _Block Party_Parade_Motorcade_Rally/Public Gathering VWalk/Run r r 1 hi(.-It L;1� N, .� STREET CLOSINGS OR AREA TO BE USED Additional Information REQUIRED from event producer/planner/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 run/walk a map of your route • Provide a Certificate of Insurance listing the City of Jeffersonville as an additional Insured for$.1,000,000%1,11(1 • Provide a cleanup plan.Producer/Planner is required to leave City property and surrounding area clean and Iitter free after the event HOLD HARMLESS AND IDEMNIFICATION CLAUSE The applicant/Event Producer/Planner shall indemnify,hold harmless and defend the City of Jeffersonville and the Jeffersonville Parks&Recreation Department,their elected and appointed officials,employees,agents and successors in interest from all claims,damages,losses and expenses including attorneys'fees,arising out of or resulting,directly or indirectly,from the Applicant/Event Producer's(or Applicant/Event Producer's subcontractors,if any)performance or breach of the contract provided that such claim,damage,loss of expenses is:(1)attributable to personal innot jury, bodilyulting injury,the negligent death,ortoinjurycn or destruction sconduct of the City offJeffe sonville or thng the loss of use e Jefferson ll ere from. Parks&breach Recr of Department,tract,and )their causedlectsby the pointe nt actic or and or willfulm elected and appointed officials and employees acting within the scope of their employment.This hold Harmless and Indemnification Clause shall in no way be limited by any financial responsibility or insurance requirements and shall survive the termination of the Small Event Permit Application. Only applicants in good standing with the City of Jeffersonville will be considered for Approval.Any misrepresentation in this application or deviation from the final approval specifications and activities described herein or failure to abide by all Federal,State and City of Jeffersonville laws, ordinances,policies and procedures may result in the immediate revocation of the approved permit and/or refusal to issue a permit in the future. �/� L25 l OL- l /qa.\ Qt ✓�%� -6 ate Rec tpf# X icrfATURL x 11�RI D\ I e Jai �i}.�«'iH 1 ►. il� t =.-:v -- Safety otee U I 'a. "o •s/$eet rarks o tee 4-6-I9 KGs Th-PtN.0 N i 1 S idAW_ fl---1- 6[64 sTA--Th N ,.....„.........40 LEADSOU-01 CSTEIN '`,i`�RLY CERTIFICATE OF LIABILITY INSURANCE DAT/25/2D/YYYY) 3/25/2019 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 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(s). PRODUCER CONTACT Pamela Bennett Martin Bennett&Bennett Insurance Inc PHONE I FAX 351 East Chestnut St. (A/C,No,Ext): (A/C,No): Corydon,IN 47112 ADDRESS:pam@bennettinS.COm INSURER(S)AFFORDING COVERAGE NAIL# INSURERA:WEST BEND MUTUAL INSURED INSURER B:FIRST COMP UNDERWRITERS Leadership Southern Indiana INSURER C: 8204 Hwy 311 INSURER D: Sellersburg,IN 47172 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 ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE INSD WVD ,(MM/DDIYYYYI,IMM/DD/YYYY! A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 1492299 10/19/2018 10/19/2019 PREM SES(Ea occurrrence) $ 300,000 MED EXP(Any one person) $ 1,000 PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO LOC PRODUCTS-COMP/OP AGG _$ 2,000,000 JECT OTHER: $ COMBINED SINGLE LIMIT 1,000,000 A AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO 1492299 10/19/2018 10/19/2019 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ X HIRED X NON-AWNED ( r PROPERTY DAMAGE $ AUTOS ONLY — AUTOS ONLY $ A UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE 1492299 10/19/2018 10/19/2019 AGGREGATE $ DED RETENTION$ $ 1,000,000 B WORKERS COMPENSATION PEA UTE ETH AND EMPLOYERS'LIABILITY Y/N WC0129620-08 10/19/2018 10/19/20191,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) "Certificate is subject to all terms,conditions and limitations in present use by the insurance companies." cs April 6,2019-Dog Walk for Dogs Helping Heroes Big 4 Station Park Sidewalk&Pavilion City of Jeffersonville is added as an Additional Insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Jeffersonvelle ACCORDANCE WITH THE POLICY PROVISIONS. Jeffersonville Parks Department 500 Quartermaster Court Jeffersonville,IN 47130 AUTHORIZED REPRESENTATIVE �) % �``\ ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD