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Temp. Street Closing - OCA Field DayJan. 8. 2018 3 10P No. 0208 P. 1 �'• �'"'•- ,�` `"' = .p _ Page 1 of 3 CITY OF OKEECHOBEE 55 SE THIRD AVENUE OKEECHOBEE, FL 34974 : Tele: 863463-3372 ext. 218 Fax: 863-763-1686 AND/ORIPPIRMOMMTRErril PERMIT APPLICATION Date Received: 1'E I i 8 Date Issued: , :1.1-11- 1. 1.1JApplication ApplicationNo: / g -0o), , Date(s) of Event: Fr iclay , Feb q a 01 g Information: Organization: getrA04,0Ten5lo,Y1 Tax Exempt No: qS- 20\50311761.0G -0 Mailing Address: fr'` er 1 -1 Di 5 VYbi-i , Contact Person: yYleA I_,CL l:l n E -Mail Address: (Y11C.IYI OOCO-e mol 1 . CUYY1 Telephone: \J Work: cal.p '6 "Ilo3 3071 _ Home: Cell: Summary of activities: 60 may_ efiudenV) w al he C -- -h me ek- a.Q.t cla,La. Proceeds usage: Please cheek requested Parks: Flagler Parks: a City Hall Park ❑ #1 Memorial Park o #2 o #3 o #4 o #5 o #6 OR Address of event: 10 S 'cxr-Ott" Ave_ ( rim ; Aim i i e,.i -To 0AGE- & Parcell : 1-g-1- -7-7)5-co,-A0-Cp-p.0o-OD 14 \Nc \AIA\ 50(16 rIst.&-ronQe do carnoAj- lohc 1 1\- (1n- V€..S . Jan. 8. 2018 3:10PM No. 0208 Page 2 of TEMPORARY STREET AND SIDEWALK CLOSING INFORMATION (If not using Park(s), provide event address) 10 s ?aero-- itlf,e, oLecon owe. 3qq ,4 Street Address City State Zip Code Street(s) to be closed: ,., cr1GtAti, ry-i e lob -h Sh Qe,-i— `j am Date(s) to be closed: rY-j , r -e q l Time(s) to be closed: ea (y) — 1 p rY a.nool Purpose of Closing: Fi e IC1 c3c,q cd- Attachments Required: Charitable Function 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. ► Site Plan ► Copy of liability insurance in the amount of $1,000,000.00 with the City of Okeechobee as additional insured. ►Proof of non-profit status Letter of Authorization from Property Owner ► 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. I. 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. ► Durnpsters 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. Jan. 8.2018 3 10P No. 0208 Page 3 of 3 I hereby acknowledge that I have read and completed this application, the attached Resolutions 08 and 04-03, concerning the use and the rules of using City property, that the information that I am the duly authorized agent of the organization. I agree to conform with, abide by rules and regulation, which may be lawfully prescribed by the City Council of the City of Okeechobee, its officers, for the issuance of this Charitable Function Permit. CERTIFICATE OF INSURANCE MUST NAME CITY OF OKEECHOBEE AS ADDITIONAL INSURED. /l l 11 / ' )an B DOI g No.(s) 03- is correct, and and obey all the or Applicant Signature Date ••••OFFI USE ONLY**** Staff Review t.'. Fire Department: Date: a cif an lI Building Official: rG. - I • Date: 1 ' S '1 cb Public Works: 1 ` Date: l - _ 1 ° Police Department:/I/P Date: /` %P BTR Department: � ap4.% 1 Date: / — 9-' / g City Administrator: Date: I City Clerk: 4 1 f`k,� Date: P l oi-18 NOTE: APPLICATION AND INSURANCE CERTIFICATE MUST BE COMPLETED RETURNED TO THE GENERAL SERVICES DEPARTMENT THIRTY (30) DAYS 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 AND PRIOR TO 1 - it, - IF Date 1 - li • 1 Y. Date ACOR UP CERTIFICATE OF LIABILITY INSURANCE kiii..----- DATE(MM/DD/YYYY) 01/15/2018 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 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 JDA Insurance Group 120 N Federal Hwy#301 Lake Worth , FL 33460 CONTACT NAME: Danielle Marcinek NE (Arc No, Ext), (561) 296-0373 FAX No 5612960392 MAIL ADDRE ohn thejda rou com ADDRESS: � @ ) 9 P• INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Philadelphia Indemnity Insurance Company 18058 INSURED Okeechobee Christian Academy 701 South Parrott Ave Okeechobee, FL 34974 INSURER B : Philadelphia Indemnity Insurance Company 18058 INSURER C : Philadelphia Indemnity Insurance Company 18058 INSURER D : Bridgefield Employers Insurance Company 10701 INSURER E : Philadelphia Indemnity Insurance Company 18058 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 LTR TYPE OF INSURANCE NSR UBR SWVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP /Y (MM/DDYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY Y N PHPK1683861 07/01/2017 07/01/2018 EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000.00 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5,000.00 PERSONAL & ADV INJURY $ 1,000,000.00 GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE X POLICY LIMIT APPLIES PRO JECT PER: LOC PRODUCTS - COMP/OP AGG $ 2,000,000.00 $ B AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED AUTOSSCHEDULED HIRED AUTOS — X AUTOS NON -OWNED AUTOS N N PHPK1683861 07/01/2017 07/01/2018 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000.00 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ _ PROPERTY DAMAGE (Per accident) $ $ C UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE N N PHUB593098 07/01/2017 07/01/2018 EACH OCCURRENCE $ 1,000,000.00 AGGREGATE $ 1,000,000.00 DED X RETENTION $ 10,000.00 $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N N/ A N 830-39477 07/02/2017 07/02/2018 WC STATU- TORY LIMITS X OTH- ER E.L. EACH ACCIDENT $ 1,000,000.00 E.L. DISEASE - EA EMPLOYEE $ 1,000,000.00 E.L. DISEASE -POLICY LIMIT $ 1,000,000.00 E Professional Liability PHPK1681466 07/01/2017 07/01/2018 Directors & Officers $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule if more space is required) The City of Okeechobee & R.E. Hamrick Testamentary Trust is named as Additional Insured in regards to the General Liability portion of policy. CERTIFICATE HOLDER CANCELLATION City of Okeechobee R.E. Hamrick Testamentary Trust 55 SE 3rd Ave Okeechobee, FL 34974 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE t 14 A1i,1 E 1,0- -14 ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SW Lith St anV uoilpd S SE 6th St SE 6th Sr OVeeckkotee, Girt stickA AMU Christ FON:PA/ship Ckeethobe SE 6th St SE 6th St cf-74, elosirt9 he g-4 0) 117 t1/43 Ct. ra D m Ned SE ith--St 0 + GootLcae Boarding:fit:1re: — y-: Detail by Entity Name Page 1 of 2 FLORIDA DEPARTMENT OfSTATE DIVISION OF CORPORATIONS DIVISION of ,41•z CORPORATIONS an official State of Florida website Department of State / Division of Corporations / Search Records / Detail By Document 1\1,1A -ibex / Detail by Entity Name Florida Not For Profit Corporation OKEECHOBEE CHRISTIAN ACADEMY, INC. Filing Information Document Number N07000007355 FEI/EIN Number 26-0443439 Date Filed 07/26/2007 State FL Status ACTIVE Principal Address 701 SOUTH PARROTT AVENUE OKEECHOBEE, FL 34974 Mailing Address 701 SOUTH PARROTT AVENUE OKEECHOBEE, FL 34974 Registered Agent Name & Address REYNOLDS, NICHOLAS L 701 SOUTH PARROTT AVENUE OKEECHOBEE, FL 34974 Name Changed: 09/01/2009 Officer/Director Detail Name & Address Title D REYNOLDS, NICHOLAS L 3342 SW HOSANAH LANE OKEECHOBEE, FL 34974 Title D SMITH, DALE P.O. BOX 742 OKEECHOBEE, FL 34973 Title D TUCKER, BRANDON httn://search. sunbiz.org/Inauirv/CornorationSearch/SearchResultDetail?inaui... 1/8/2018 Detail by Entity Name Page 2 of 2 104 NW 7TH AVENUE OKEECHOBEE, FL 34972 Title D RENO, SARAH D 405 S.W. 2ND STREET OKEECHOBEE, FL 34974 Title D O'NEILL, ROBERTA 5593 NW 20TH STREET OKEECHOBEE, FL 34972 Title D Rucks, Heather W 2240 NW 144th Drive OKEECHOBEE, FL 34972 Annual Reports Report Year Filed Date 2015 01/06/2015 2016 01/25/2016 2017 01/12/2017 Document Images 01/12/2017 -- ANNUAL REPORT 01/25/2016 -- ANNUAL REPORT 01/06/2015 -- ANNUAL REPORT 01/14/2014 -- ANNUAL REPORT 01/28/2013 — ANNUAL REPORT 01/05/2012 -- ANNUAL REPORT 01/05/2011 — ANNUAL REPORT 03/17/2010 -- ANNUAL REPORT 09/01/2009 —ANNUAL REPORT 03/25/2009 — ANNUAL REPORT 02/26/2008 —ANNUAL REPORT 07/26/2007 -- Domestic Non -Profit View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format Florida Department of State, Division of Corporations htta://search. sunbiz. ora/Inauirv/CoraorationSearch/SearchResultDetail?inaui... 1 /8/2018 Jackie Dunham From: Jackie Dunham Sent: Wednesday, January 17, 2018 8:23 AM To: mking.oca@gmail.com Cc: mhamrick@manateelegal.com; gil@gilberthasit.com; David Allen; Kay Chapman (kchapman@cityofokeechobee.com) Subject: Upcoming Street Closing Please be advised that your request to close SE 2"d Avenue from SE 6th Street to SE 7th Street on Friday, February 9th, 2018 from 8AM to 1PM for Okeechobee Christian Academy's annual Field Day was approved at the City Council meeting held January 16, 2018. Thank you for your cooperation in providing the application request in a timely manner and much success for your event. Jacckde/ Dukn.havvv Adini411.4tratwe, Secretary Ccty of Okeechal 55 SE 1 hi,rd/Avevute Okeechal, FL 34974 863 -763-3372 (Mt vv) 863-763-9821 (Di.rect) 863-763-1686 (Eaao) j dunham(a,cityofokeechob ee. com Website: http://www.cityofokeechobee.com NOTICE: Due to Florida's broad public laws, this email may be subject to public disclosure. 1