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Temp. Use Permit - American Legion Free FairCity of Okeechobee 55 S.E. 3 d Avenue Okeechobee, Florida 34974 (863) 763-3372 Temporary Use Permit Permit Number: 18-001 Date(s) of Event: 2-1-18 thru 2-10-18 (5P -12A Weekday; 12P - 12A Weekends) Permit Expiration: February 10, 2018 11:59PM Purpose of Request: American Legion Free Fair Property Owner: American Legion Post 64 Address: 501 SE 2nd Street City: Okeechobee State: Florida Applicant: American Legion Post 64 Phone Number: 863-763-2950 Current Zoning: Residential Multiple Family (RMF) Subdivision: 1 st Addition to City of Okeechobee Zip Code: 34974 Applicant's Address: 501 SE 2nd Street Address of Project: 501 SE 2nd Street FLU Designation: CommercigL (C) Restrictions/Remarks: All debris must be removed upon final completion date. Owner understands and agrees to the following: X Issuance of a permit may be subject to other conditions and time limitations. X Issuance of a permit is not authorization to violate public or private restrictions. X Failure to comply with applicable regulations may result in withholding future permits. X There may be additional permits required from other governmental entities. NO SET UP OR TEAR DOWN BETWEEN THE HOURS OF 12 MIDNIGHT AND 7:00 A.M. 48 HRS AFTER FAIR CLOSING, PROPERTY MUST BE VACATED. TRASH MUST BE PICKED UP DAILY IN PARKING LOT AT CITY HALL. I ce cafit's S iministrative Secretary F:.ORD.716, Temporary Structures is correct and I will abide by its requirements. Date ADAM H. PUTNAM COMMISSIONER MEGERLE SHOWS PO BOX 310 GIBSONTON, FL 33534 Division of Consumer Services/Bureau of Fair Rides Inspection EVENT REPORT Phone 1-800-435-7352; Fax (850) 410-3797 FairRides@FreshFromFlodda.com INVOICE #: 3026174 PURPOSE: Scheduled EVENT NAME: OKEECHOBEE AMERICAN LEGION EVENT ADDRESS/LOCATION: 501 SE 2ND STREET EVENT CITY/COUNTY: OKEECHOBEE/OKEECHOBEE OPEN DATE: 02/02/2018 INSPECTION #: 1801-01250 # Rides: 11 # Rides Passed: 11 # Rides Failed: 0 # Rides Not Ready: 0 # Go Karts: 0 # Go Karts Passed: 0 1# Go Karts Failed: 0 # Go Karts Not Ready: 0 USAID I Theme Name Status I IC/RT # I Deficiency OST # Unit 07699 PCEAN TRIP Pass 1 193482 kttachments - Restraints: Latches damaged/not working 12776 5 ttachments - Restraints: Wom 12276 6 09826 ROP TOWER Pass 193483 Dperation - Limit Controls: Inoperable 12280 3 10939 IRCUS TRAIN Pass 193499 12172 OCK-N-ROLL Pass 193484 3peration - Brakes: Inoperable 12779 7 Aeration - Brakes: Inoperable 12102 9 12260 VANG 10 Pass 193485 12451 FAERRY GO ROUND Pass 193486 Attachments - Canierfrubs: Not properly secured 12650 13 Attachments - Carrierlrubs: Not properly secured Attachments - Carrier/Tubs: Not properly secured 8382 12649 28 9 14339 UN SLIDE Pass 193487 14704 AMPTON DUNE BUGGY Pass 193488 14792 COOTERS Pass 193489 Attachments - Carner/Tubs: Damaged 12780 8 15034 OTORCYCLES Pass 193490 15035 O GATOR Pass 193491 F] I acknowledge that all identified rides issued a stop operation order (RT #) and/or carriers or components issued an out of service (OST #) are not in compliance with Florida Statute 616.242 and/or Rule Chapter 5J-18, F.A.C. Further deficiencies may still exist and ride(s) shall not operate until it passes a subsequent inspection by the Department. Insp Npme., v� 2-2—I g Owner/Manager Date ADAM H. PUTNAM COMMISSIONER Division of Consumer Services/Bureau of Fair Rides Inspection J & J AMUSEMENTS PO BOX 485 NEW MIDDLETOWN, OH 44442 EVENT REPORT Phone 1-800-435-7352; Fax (850) 410-3797 FairRides@FreshFromFlorida.com INVOICE #: 3031968 PURPOSE: Scheduled EVENT NAME: OKEECHOBEE AMERICAN LEGION EVENT ADDRESS/LOCATION: 501 SE 2ND STREET EVENT CITY/COUNTY: OKEECHOBEE/OKEECHOBEE OPEN DATE: 02/02/2018 INSPECTION #: 1801-01250 # Rides: 7 # Rides Passed: 6 # Rides Failed: 0 # Rides Not Ready: 1 # Go Karts: 0 # Go Karts Passed: 0 # Go Karts Failed: 0 # Go Karts Not Ready: 0 USAID Theme Name Status IC/RT # Deficiency OST VT74nit 08211 ARATROOPER Pass 193492 08335 3UPER JET Pass 193493 08356 3EAR AFFAIR Pass 193494 08357 OMBO Pass 193495 Aftachments - Restraints: Worn 10694 #2 Attachments - Carrier/Tubs: Damaged 09626 FIRE 09818 WING CAROUSEL Not Ready 14314 INO Pass 193497 15087 ONDOLA WHEEL Pass 193498 I acknowledge that all identified rides issued a stop operation order (RT #) and/or carriers or components issued an out of service (OST #) are not in compliance with Florida Statute 616.242 and/or Rule Chapter 5J-18, F.A.C. Further deficiencies may still exist and ride(s) shall not operate until it passes a subsequent inspection by the Department. Insp Name 2 — 2 Q�vn&rffllahager Date 1 A� 0® CERTIFICATE OF LIABILITY INSURANCE ) rATE 1/29/2018 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 Higginbotham Insurance Agency, Inc. 500 W. 13th Street Fort Worth TX 76102 CONTACT Michele Lane PHONE FAx . 800-728-2374 AC.Nol: 817-347-6981 ADDRESS: miane@higginbotham.net INSURERS AFFORDING COVERAGE NAIC # INSURER A: Hartford Fire Insurance Company 19682 5082984796 INSURED POWER31 Powerhouse Retail Services, LLC The Powerhouse Retail Services, LLC of Iowa INSURER B: Aspen American Insurance Company 43460 INSURER C: Continental Casual Company 20443 INSURER D: Valley Fore Insurance Company 20508 Powerhouse Partners, LLC 812-A South Crowley Road Crowley TX 76036 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 1910157783 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 ADDL SUBR POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MM/DDIYYYY LIMITS C X COMMERCIAL GENERAL LIABILITY 5082984796 2/1/2018 2/1/2019 EACH OCCURRENCE $1,000,000 CLAIMS -MADE � OCCUR DAMAGE( RENTED PREMISESSEa occurrence) $100,000 MED EXP (Any one person) $15,000 X Ded:$5,000 PD PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY F -i -] JELOC PRODUCTS -COMP/OP AGG $ 2,000,000 $ OTHER: D AUTOMOBILE LIABILITY 5082984880 2/1/2018 2/1/2019 OMBINED SINGLE LIMIT 52,'.' Ea accident $1,000,000 BODILY INJURY (Per person) $ X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE $ Per accident B X UMBRELLA LIAB X OCCUR CX0056718 2/1/2018 2/1/2019 EACH OCCURRENCE $10,000,000 AGGREGATE $10,000,000 EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ C C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N 5082984846 4025670115 2/1/2018 2/1/2018 2/1/2019 2/1/2019 X SPER TATUTE OERH ANY OFFICER/MEMBER EXCLUDED? ECUTIVE � N /A E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA E:MP:LO:Y:Ed $1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below I IE.L. DISEASE - POLICY LIMIT $1,000,000 C Leased/Rented Equipment 5082984796 2/1/2018 2/1/2019 Per Item $75,000 Max $250,000 A 3rd Party Crime 46TP029943417 12/13/2017 2/1/2019 $2,000,000 $25,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Workers Compensation policy **4025670115 includes only the State of California. Workers Compensation policy **5082984846 includes all states except North Dakota, Ohio, Washington, Wyoming, California and Alaska. Workers Compensation policies **5082984846 and **4025670115 excluded officers: All active officers are excluded. General Liability policy 50829874796 includes Stop Gap endorsement for Ohio and Washington. See Attached... CERTIFICATE HOLDER CANCELLATION City of Okeechobee 55 SE Third 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 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD ACO DR AGENCY CUSTOMER ID: POWER31 LOC #: ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Higginbotham Insurance Agency, Inc. Powerhouse Retail Services, LLC The Powerhouse Retail Services, LLC of Iowa Powerhouse Partners, LLC POLICY NUMBER 812-A South Crowley Road Crowley TX 76036 CARRIER NAIC CODE EFFECTIVE DATE: r_1anur•,r_n THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE The General Liability and Automobile Liability policy includes a blanket automatic additional insured endorsement that provides additional insured status (General Liability includes Completed Operations) and General Liability, Automobile Liability and Workers' Compensation policy includes a blanket waiver of subrogation endorsement to any person or organization whom the Named Insured has agreed to add in a written agreement. The General Liability policy has a blanket Primary & Non Contributory endorsement that affords that coverage to any person or organization whom the Named Insured has agreed to add in a written agreement. The General Liability includes Sudden and Accidental Pollution The General Liability and Automobile Liability and Workers Compensation "5082984846 policies include a blanket notice of cancellation to certificate holders endorsement, providing for 30 days' advance notice if the policy is canceled by the company other than for nonpayment of premium, 10 days' notice after the policy is canceled for nonpayment of premium. Notice is sent to certificate holders with mailing addresses on file with the agent or the company. The endorsement does not provide for notice of cancellation if the named insured requests cancellation. Umbrella is follow form regarding the General Liability, Automobile Liability, and the Workers' Compensation policies. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CITY OF OKEECI•IOBEE General Services Department, Room 101 55 Southeast 3" Avenue 7� Okeechobee, FL 34974 Phone: 863-763-3372 gW= Fax: 863-763-1686 y.CF40 DATE RECEIVED: DATE ISSUED: 17 APPLICATION NO: DATE(S) OF EVENT' - FEE: $175.005 P- DATE PAID: ❑,l If Non-Profit/Civic Or anization -j-7 TEMPORARY USE PERMIT APPLICATION OTHER TEMPORARY STRUCTURES SEC 666 Name of Property Owner(s)oe- Address: ��f �J L) Telephone Numbers: H y��` rk: &,,77631ell: Pager: CL Name of Applicant' � Address: -jai' � `� Ok fCh p6 ' J 3 -Oe� Telephone Numbers: Home: Work (.3.-.2ile/Cell: Pager: IdP-�� to,F "Ki - - -rr, - vvl lvv. 1 110 1111y-c-lvii muiuue❑ in Inls application is for use by the City of Okeechobee in processing my request. False or misleading Information may be punishable by a fine of up to $500.00 arLd imprisonment of up to thirty da s and may result in the summary denial of this application. -7 Signature of Applicant Date Cltv Staff (Pieria raviaw tha 7nn1innf;^ ++—k ---_.,—_----••—�•........ ...+ v. v a+vlal vVIIVlU VI1� Occupational and/or State License Verification. 1 Future Land Use Map Designation: ok Current Zoning Designation: C Legal Description of Property: Fire Department Approval: Address of Property: &/X06 C- Please Explain Type of Use: "�� Police Department Approval: Briefly describe use of adjoining property: North: I Q= l" East: Public Works Department Ap Date: South: SIJL� ✓/4f. ljetie5 West: C'S/ �� i9� d✓iG Building Inspector Apprc al: Other temporary structures subject to the following regulations: LU 0 1. Christmas tree, fireworks and similar seasonal sales operated, by a non-profit organization. CL 2. Carnival, circus, fair or other special event operated by a non-profit organization on or abutting their principal use. ' City Administrator Approval:"tik 3. Commercial carnival, circus or fair in commercial or Industrial districts. 4. Similar temporary structures where the period of use will not exceed 30 days a year. Thent shall: Submit proof of liability insurance, paid in full covering the period for which the permit is issued, in the minimum amount of $1,000,000.00 per occurrence. Remove all debris within 48 hours of expiration of permit Have notarized written permission of property owner, If applicant is not the property owner. �bmit Site Plan 5. Submit State Inspection Certificate(s) 6. Submit State Annual Permit herebv cartifv that tha infnrm m4inn nn +k- - ..li - - -rr, - vvl lvv. 1 110 1111y-c-lvii muiuue❑ in Inls application is for use by the City of Okeechobee in processing my request. False or misleading Information may be punishable by a fine of up to $500.00 arLd imprisonment of up to thirty da s and may result in the summary denial of this application. -7 Signature of Applicant Date Cltv Staff (Pieria raviaw tha 7nn1innf;^ ++—k ---_.,—_----••—�•........ ...+ v. v a+vlal vVIIVlU VI1� Occupational and/or State License Verification. 1 C Date: 9� Fire Department Approval: Date: l Police Department Approval: Date: Public Works Department Ap Date: 1Z'2 -D ' 17 Building Inspector Apprc al: Date: City Administrator Approval:"tik 7 UO) SF 3u Rrg- _.— ----- ----- --- 0 Q PAU., R,% RIDF �.:Gad,CSSi s ��-�,�,� To � C�ZS. � -rA A WE 6cl, 1 0 C) (kc) CC) c.,