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Park Use Permit-2017 Holiday Cards in the ParkCITY OF OKEECHOBEE 55 SE THIRD AVENUE OKEECHOBEE, FL 34974 Tele: 863-763-3372 ext. 9821 Fax: 863-763-1686 e-mail: jdunham(c�cityofokeechobee.com Park Use Permit Permit Number: 021 Date(s) of Event: Nov 11, 2017 — Jan 8, 2018 Permit Expiration: January 10, 2018 11:59 P.M. Purpose of Request: Display 4x8, 8x8 Cards for Individuals/Businesses Property Owner: City of Okeechobee Address: 55 SE Third Avenue City: Okeechobee State: Florida Zip Code: 34974 Applicant: OHS Band Phone Number: 863-801-7673 or 863-447-5509 Current Zoning: P Subdivision: City of Okeechobee Applicant's Address: 2800 Hwy 441 North Address of Project: Park #6 FLU Designation: Public Restrictions/Remarks: All debris must be removed within 24 hours of expiration date. ..Tacc kieJ Administrative Secretary/General Services 11/1/17 Date 10/3012017 09:49 INDIAN RIVER STATE COLLEGE 17A)Q8638246019 2.6 P.002 Page 1 of 3 CITY OF OKEECHOBEE 55 SE THIRD AVENUE OKEECHOBEE, FL 34974 Tele: 863-763-3372 ext. 218 Fax: 863-763-1686 PARK USE AND/OR TEMPORARY STREET/ SIDEWALK CLOSING PERMIT APPLICATION Date Received: i C . . - / 7 Date Issued: E -Mail Address: Iaflamcl@okee,k12.fl.us, cworlow96@gmail.com A slication No: 0 Date s of Event: 1(a'. D 014- - O • 143 J Information: Organization: OHS MARCHING BAND Tax Exempt No: 85-2012622249C-3 Mailing Address: 2800 HIGHWAY 441N, OKEECHOBEE, FL 34972 Contact Person: CLINT LAFLAM, CHERYL WORLOW E -Mail Address: Iaflamcl@okee,k12.fl.us, cworlow96@gmail.com Telephone: Work: CLINT - 863-801-7673 Home: CHERYL - 863-447-5509 Cell: Summary of activities: INSTALL 4' X 8' SHEET OF MATERIAL BILLBOARDS FOR CHRISTMAS & HOLIDAY GREETINGS TO THE COMMUNITY HOLIDAY STROLL IN THE PARK PROJECT Proceeds usage: GENERAL BAND EXPENSES, STUDENT BAND FEES, AND PURCHASE ADDITIONAL UNIFORMS FOR THE GROWING BAND Please check requested Parks: Flagler Parks: o City Hall Park ❑ #1 Memorial Park ❑ #2 o #3 o #4 o #5 )c #6 SOUTHEAST OR CORNER OF BLOCK Address of event: Parcel ID: 10/30/2017 09:49 INDIAN RIVER STATE COLLEGE (FAX)8638246019 3/`i P.003 TEMPORARY STREET AND SIDEWALK CLOSING INFORMATION (If not using Park(s), provide event address) Street Address Street(s) to be closed: Date(s) to be closed: City Page 2 of State Zip Code Time(s) to be closed: Purpose of Closing: Attachments Required: Charitable Function ► Site Plan ► Copy of liability insurance in the amount of 51,000,000.00 with the City of Okeechobee as additional insured. ► Proof of non-profit status ► Letter of Authorization from Property Owner ► State Food Service License, if applicable. Temporary Street and Sidewalk Closing ► Original signatures of all residents, property owners and business owners affected by the closing. ► Copy of liability insurance in the amount of 51,000,000.00 with the City of Okeechobee as additional insured. ► If any items are being sold on City streets or sidewalks, a Temporary Use Permit (TUP) must be attached for each business. TUP can be obtained from the General Services Department. ► State Food Service License, if applicable. ► State Alcoholic Beverage License, if applicable. (Alcoholic beverage can be served only on private property. No alcoholic beverages are allowed on City property, this included streets and sidewalks.) Note: ► Clean-up is required within 24 hours. ► No alcoholic beverages permitted on City property, streets or sidewalks. ► No donations can be requested if any type of alcoholic beverages are served on private property/business unless you possess a State Alcoholic Beverage License. Please note there are inside consumption and outside consumption licenses. You must have the appropriate license(s). ► The Department of Public Works will be responsible for delivering the appropriate barricades, ► Dumpsters and port -o -lets are required when closing a street for more than three (3) hours. Applicant must meet any insurance coverage and code compliance requirements of the City and other regulations of other governmental regulatory agencies. The applicant will be responsible for costs associated with the event, including damage of property. By receipt of this permit, the applicant agrees and shall hold the City harmless for any accident, injury, claim or demand whatever arising out of applicant's use of location for such event, and shall indemnify and defend the City for such incident, including attorney fees. The applicant shall be subject to demand for, and payment of, all of the actual cost incurred by the City pertaining to the event including, but not limited to, Police, Fire, Public Works or other departmental expenses. The City reserves the right to require from an applicant a cash or cashier's check advance deposit in the sum approximated by the City to be incurred in providing City services. Any such sum not incurred shall be refunded to the applicant. 10/3012017 09:49 INDIAN RIVER STATE COLLEGE (FAX)8638246019 P.004 Page 3 of 3 I hereby acknowledge that I have read and completed this application, the attached Resolutions No.(s) 03- 08 and 04-03, concerning the use and the rules of using City property, that the information is correct, and that I am the duly authorized agent of the organization. I agree to conform with, abide by and obey all the rules and regulation, which may be Lawfully prescribed by the City Council of the City of Okeechobee, or its officers, for the issuance of this Charitable Function permit. CERTIFICATE OF INSURANCE MUST NAME CITY OF OKEECHOBEE AS ADDITIONAL INSURED. Applicant'ignature iDi2L.) 12,D Y9 Date ••••OFFICE USE ONLY"" Staff Review Fire Department: Building Official: Public Works: Police Department: BTR Department: City Administrator: City Clerk: Date: Cilt v20/7 Date: • 3y 4% Date: /O -3o --j) Date:/.fe) /7 D ��� a0/7 Date: Date: it)(3biaari NOTE: APPLICATION AND INSURANCE CERTIFICATE MUST BE COMPLETED AND RETURNED TO THE GENERAL SERVICES DEPARTMENT THIRTY (30) DAYS PRIOR TO EVENT FOR PERMITTING, Temporary Street and Sidewalk Closing submitted for review by City Council on Temporary Street and Sidewalk Closing reviewed by City Council and approved Date Date Page 1 of 2 ACRD® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 10/31/2017 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 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 Willis Administrative Services Corporation DBA Willis Pooling c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 372305191 USA CONTACT NAME: POLICY EFF (MM/DD/YYYY) PHONE 1-877-945-7378 FAX 1-888-467-2378 IA/C.No. ExO: (A/C, No): E-MAIL ADDRESS: certificates@willis.com INSURER(S)AFFORDINGCOVERAGE _ NAIC# INSURERA: Florida School Boards Insurance Trust D2772 INSURED Okeechobee County School District Attn: Chris Lawrence 700 SW Second Avenue Okeechobee, FL 34974 INSURER B : INSURERC: EACH OCCURRENCE INSURERD: INSURER E : CLAIMS -MADE INSURER F : OCCUR COVERAGES CERTIFICATE NUMBER: W4231639 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 LTR TYPE OF INSURANCE ANBD DDL SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MMIDDIYYYY) LIMITS { 1-f1D ' 4� W S� X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE X OCCUR DAMAGE TO D PREMISES EaENToccurrence) $ Included A MED EXP (My one person) $ Excluded FSBIT17CAS7-1 07/01/2017 07/01/2018 PERSONAL BADV INJURY $ Included GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ Unlimited POLICY PRO PRO JECT LOC PRODUCTS - COMP/OP AGG $ Included OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 X ANY AUTO BODILY INJURY (Per person) $ A OWNED AUTOS ONLY SCHEDULED AUTOS FSBIT17CAS7-1 07/01/2017 07/01/2018 BODILYINJURY(Peraccident) $ AUTOS ONLY HIRED X Y AUTOS ONLY PROPERTYDAMAGE ( accident) $X $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB `— CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION X STATUTE ER A AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y / N No E.L. EACH ACCIDENT $ 2,000,000 OFFICER/MEMBEREXCLUDED? (Mandatory in NH) NIA FSBIT17CAS7-1 07/01/2017 07/01/2018 E.L. DISEASE - EA EMPLOYEE $ 2,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) This Voids and Replaces Previously Issued Certificate Dated 10/27/2017 WITH ID: W4192965. For the General Liability policy, General Aggregate is Unlimited. Evidence of Coverage in respect to Okeechobee High School Band having Holiday Stroll in the Park from November 11, 2017 thru January 8, 2018. The display of 4X8 and 8X8 billboards for individual businesses. The billboards will be CERTIFICATE HOLDER CANCELLATION ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID: 15264531 BATCH: 497656 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 Okeechobee AUTHORIZED REPRESENTATIVE 55 SE 3rd Avenue Okeechobee, FL 34974 { 1-f1D ' 4� W S� ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID: 15264531 BATCH: 497656 ACO AGENCY CUSTOMER ID: LOC #: ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY Willis Administrative Services Corporation DBA Willis Pooling NAMED INSURED Okeechobee County School District Attn: Chris Lawrence 700 SW Second Avenue Okeechobee, FL 34974 POLICY NUMBER See Page 1 CARRIER See Page 1 NAIC CODE See Page 1 EFFECTIVE DATE: See Page 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE• Certificate of Liability Insurance located at the SE corner of Park #6. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID: 15264531 BATCH: 49656 CERT: W4231639