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HomeMy WebLinkAboutsira cguku ciij iff T ��'VYYrr iy, o • CITY EVENT PERMIT APPLICATION For events,block parries,parades,walks,nuns and public rallies Return to:Jeffersonville Parks Department,500 Quartermaster Ct.,Jeffersonville,IN 47130 Additional information contact:812-285-6440,Fax:812-285-6481 • EVENT NAME: S \ r t YIL�IO \Q . fZera uS e) u ()o k. Cff Official name of festival or event CONTACT/PRODUCER: t? 1 Ci.t I (c,�}tf A )/ errs &lor Producer to be contacted regarding event CONTACT ADDRESS: ata ',C. -,t & uUES1 INS 41130 Street l / City �p State Zip CONTACT INFO: gIC�,"9 } ,- rr qQ t { ) ftr'thow (�02gfrcLuvr Day Phone Cell Phone Fax E-mail EVENT INFORMATION _ Event location address: ' k Folk StOjt]( 1'Z, `�aQ, 11.S 9!„9 „-5- Date: t t / 3 /t$ Day of week: SQh Irt a I� Time: 1 $2 _M Ending Date: 11 /_3 / t g Day of week: €21,11AVcicti Time: $ : 00 _CM Total attendance expected: Y SD }vt l}c Rain/Cancellation Policy 9_0,.(I1 " s') 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 S150(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 Motorcade Rally/Public Gathering___Walk/Run Other Futyla oC i tvtr9 FMEi'tt,faimitl t4),t, its cocv ccE ru+ STREET CLOSINGS OR AREA TO BE USED f �kQl C�\P N, 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 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/Event Producer's subcontractors,if any)performance or breach of the contract provided that such claim,damage,loss of expenses is:(I)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 specifications and activities described herein or failure to abide by all Federal,State d City of Jeffersonville laws, ordinances,policies and procedures may result is t e immediate r ocation of the apprgv`�f1, ani%vfys issue a permit in the future. X � - e r9 /as / i ;r 1q0 Pi)-CAL j i IGNATURE QUIRED . � Date Receipt# 1N-18 y_ JO /241-.1 'ore / Fire Public Worlcs/Street YarK3 Safety ACO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 09/14/2018 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 NAME: Jerry Rauck ISU Insurance and Investment Group 301 E Utica St PHONE (A1C,No.Extl: (B 12) 246-6333 �FAX (A/C,No):(812) 246-6335 E-MAIL vschillerCaisu-ii Sellerburg IN 47172 ADDRESS: g.com INSURER(S)AFFORDING COVERAGE NAIL# INSURER A:West Bend NSI INSURED INSURER B: Southern Indiana Realtor Assoc INSURER C: PO Box 2724 INSURER 0: Clarksville IN 47131 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:cert ID 2993 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 LTR TYPE OF INSURANCE JNSD WVD POLICY NUMBER FMIDDIY FF POLICY (MMlDDlYYYY) {MM/DD/YYWI LIMITS A COMMERCIAL GENERAL LIABILITY EP.CHOCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE OCCUR A509053 00 11/03/201811/04/2018 PREMISES(Ea occurrence) S 100,000 MED EXP(Any one person) $ _ PERSONAL BADV INJURY $ 1,000,000 GE 'I_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG 1 2,000,000 _ OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S IEa accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY u AUTOS ONLY (Per accident) S _ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ I DED I RETENTIONS S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT S OFFICER/MEMBEREXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S S DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) SPECIAL EVENT: CHILI COOK OFF CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Jeffersonville 500 Quartermaster Ct AUTHORIZED REPRESENTATIVE Jeffersonville IN 47130 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Page 1 of 1