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Community Outreach Page 1 of 3 Revised 3/5/19 CITY OF OKEECHOBEE •��r\�y.o eV -- 55 SE THIRD AVENUE `��; pi - :_ °gym= OKEECHOBEE, FL 34974 =o �� Tele: 863-763-9821 Fax: 863-763-1686 = ,� .;••' PARK USE AND/OR TEMPORARY STREET/ ..woo-' SIDEWALK CLOSING PERMIT APPLICATION Date Received: 0 Lk \' - 7 Date Issued: -1: P ZT j„ 2O, 3 623 Application No: '!"3— Date(s) & Times of Event: Saturday April 22, 2023 / 10a- 3pm Information: Organization: Iglesia de Dios Pentecostal Movimiento Internacional INC. Mailing Address: 2935 Suite#2941 SW 3rd Terrace, Okeechobee, FL, 34974 Contact Name: Nancy Cabrera , Sonia Cabrera 7 E-Mail Address: (772) 209-1264 , (772) 530-1695 C, s \2 t.,/ 44`2 -t_t t(, , Telephone: Work: Home: Cell: '772)209-1264 , (772) 530-1695 Summary of activities: We are planning to do a community outreach where we would have free food to give out to the community, face face painting and games for the kids, and live music we would finish off the event with a small sermon and prayer. Proceeds usage: We would like use this park/locations because it is close proximity to our church. We would only require the park itself and the electricity from city, we will provide everything else included to sound system. Please check requested Parks: Flagler Parks: ❑ City Hall Park ❑ #1 Memorial Park ❑ #2 tiff#3 o#4 ❑ #5 ❑ #6 [Park 3 is location of Gazebo. Park 4 is location of Bandstand] (If other private property used in conjunction with this Park Use Permit please provide the address and parcel number below along with notarized letter of authorization from property owner) Additional Addresses, if applicable Parcel ID: Page 2 of 3 Revised 3/5/19 TEMPORARY STREET AND SIDEWALK CLOSING INFORMATION (Street Closings require City Council approval.Meetings 1st&3`a Tuesdays but subject to change) Address of Event: 55 SE 3rd Ave Okeechobee FL 34974, Park#3 (Flag Pole + Gazebo Street(s)to be closed: N/A Date(s)to be closed: Time(s)to be closed: Purpose of Closing Attachments Required for Use of Parks Attachments Required for Street/Sidewalk Closings ► Site Plan I ► Site Plan ► Copy of liability insurance in the amount of ► Copy of liability insurance in the amount of$1,000,000.00 $1,000,000.00 with the City of Okeechobee as with the City of Okeechobee and R.E. Hamrick Testamentary additional insured. Trust as Additional Insured. ►Proof of non-profit status ✓ ► Original signatures of all residents,property owners and business owners affected by the closing. ► State Food Service License if>3 days. ► State Food Service License if>3 days. ► Notarized letter of authorization from ► State Alcoholic Beverage License, if applicable.** property owner, if applicable.* * Required if private property used in conjunction with a Park Use application. ** Alcoholic beverages can be served only on private property. Alcoholic beverages NOT ALLOWED in City Parks, City streets or City sidewalks. See additional note below. o Please check if items will be sold on City streets/sidewalks. Each business will need to apply for a Temporary Use Permit 667 along with the Street Closing application. 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 arises 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 costs 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 cashier's check or 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 of this Park Use/Street Closing Permit. APPLICATION FOR SPECIAL EVENT Application Number: Date Received: NAME OF EVENT: Community Outreach ADDRESS OF EVENT: 55 SE 3rd Ave, Okeechobee, FL 34974 II Park#3 DESCRIPTION OF EVENT: Community Outreach NAME OF SPONSOR ORGANIZATION: Ilgesia de Dios Pentecostal Movimiento Internacional Contact Number before and during event OF RESPONSIBLE PERSON: ( 772)209-1264 - RESPONSIBLE PERSON'S NAME: Nancy Cabrera Reyes DATE(S) AND TIME(S) OF EVENT: Date: April 22, 2023 Starting Time: 10:00 AM Closing Time: 3:00 PM Date: Starting Time: Closing Time: ARE ANY ROADWAYS TO BE BLOCKED/CLOSED? No LOCATION Will Emergency Apparatus(Fire and Ambulance)have access to area? Yes IF NO,THEN(provide alternatives): WILL ELECTRICITY BE USED? YES ONO O (circle) Locations: Provided By: WILL HEATING/OPEN FLAMES FOR FOOD BE PROVIDED?(circle)YES O ONO O Type of Heating Equipment Used: WILL A TENT BE ERECTED?(circle) YES O NO f Tent Manufacturer: Size fire rating posted: Tent have sides and how many? Are there Fire Extinguishers accessible and ready for use?(circle) Yes No ""ATTACH SITE MAP OF EVENT LAYOUT** FIRE SERVICES SHALL COMPLETE ITEMS BELOW: FIRE DEPARTMENT LIFE SAFETY&FIRE SERVICES REQUIREMENTS:(See above) Li Tents/canopy fire rating certificate required. Li Tent Size require life safety inspection (900 square feet or less then no permit is required) 0 Floor plan/seating/setup drawing required showing exits, etc. o Emergency access must be maintained. (REFERS TO VEHICLES AND EQUIPMENT) O Fire extinguishers must have current tag, and be operational and readily accessible. O Cooking requires LPG outside of tent pointing away from exposures. Li Electrical wiring exterior rated,not overloaded. Li Fire Services inspection required. Li Fire watch or inspector(s) REQUIRED? FIRE WATCH Amount: Li Firefighter/Inspector Amount: O Other: FIRE DEPARTMENT OFFICI (PRINT): ) (u Rost( co a fti ppr , M.c hM SIGNATURE: Please call the FD at 863-467-1586 for any questions. Revised 11-6-19 Page 3 of 3 Revised 3/5/19 I hereby acknowledge that I have read and completed this application, the attached Resolutions No.(s) 03-8 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 regulations, which may be lawfully prescribed by the City Council of the City of Okeechobee, or its officers, for the issuance Certificate of Insurance must name City of Okeechobee as Additional Insured as well as R.E. Hamrick Testamentary Trust if closing streets or sidewalks. of/`/'/2a2.j App icant Signature Date ••••OFFICE USE ONLY•••• Staff Review r Fire Department: ' Date: LI l ( 1'1 2 3 Building Official: ' Date: Public Works: �— Date:.4 / I Police Department: Date: ( 70 27 BTR Department: Date: / a City Administrator: s Date: T cP/ City Clerk: - Cht6 t^r. Date: I 1 q(a( 3 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 N/ Date Temporary Street and Sidewalk Closing reviewed by City Council and approved ift Date ..,. ,,,,, .,,,,,..\-, vdx,v-2. 0 ._ ,.... mir.., 4...' ,...„,-.:, ... . r„--,..,.. .- ,..„. _,_ . , . . . ,... , .4.-., . ., .„ f ,..,.„ ., ." , C 4'. , ' f '' s r V WLt e' 11 1 lwitJ a �/`•'�^'��! F:D a „ .- K ?; A: : r x� 1 4F'L• e• 7',,,',�f'B 41 LEI t 4 ' 0000207 10/16/21 . DR-14 /// Consumer's Certificate of Exemption R.01/18 Issued Pursuant to Chapter 212, Florida Statutes FLORIDA 85-8015784594C-4 12/02/2021 12/31/2026 501(C)(3)ORGANIZATION • Certificate Number Effective Date Expiration Date Exemption Category This certifies that IGLESIA DE DIOS PENTECOSTAL MOVIMIENTO INTERNACIONAL INC 12621 BALCOMBE RD ORLANDO FL 32837-6219 is exempt from the payment of Florida sales and use tax on real property rented,transient rental property rented,tangible personal property purchased or rented,or services purchased. 1 DR-14 important Information for Exempt Organizations R.01/18 FLORIDA 1. You must provide all vendors and suppliers with an exemption certificate before making tax-exempt purchases. See Rule 12A-1.038, Florida Administrative Code(F.A.C.). 2. Your Consumer's Certificate of Exemption is to be used solely by your organization for your organization's customary nonprofit activities. 3. Purchases made by an individual on behalf of the organization are taxable, even if the individual will be • reimbursed by the organization. 4. This exemption applies only to purchases your organization makes. The sale or lease to others of tangible personal property,sleeping accommodations, or other real property is taxable. Your organization must register, and collect and remit sales and use tax on such taxable transactions. Note: Churches are exempt from this requirement except when they are the lessor of real property(Rule 12A-1.070, F.A.C.). 5. It is a criminal offense to fraudulently present this certificate to evade the payment of sales tax. Under no circumstances should this certificate be used for the personal benefit of any Individual. Violators will be liable for payment of the sales tax plus a penalty of 200% of the tax, and may be subject to conviction of a third-degree felony. Any violation will require the revocation of this certificate. 6. If you have questions about your exemption certificate, please call Taxpayer Services at 850-488-6800. The mailing address Is PO Box 6480, Tallahassee, FL 32314-6480. DATE(MM/DD/YYYY) A C.CWD CERTIFICATE OF LIABILITY INSURANCE 04/11/2023 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 CONTNOLAN JACKSON JR. &ASSOCIATES, INC. NAME:AOT Nolan Jackson PH1455 River Cove Rd IPJC No.Extl: (770)788-7900 NE FAX No): (770)788-9010 Social Circle, GA 30025 E-MAIL E-MAIL ADDRESS: njackson@njjins.com License#: 531001 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: GuideOne Insurance Company 15032 INSURED INSURER B IGLESIA DE DIOS PENTECOSTAL MI INSURERC: 2310 SE Bordeaux Ct INSURERD: Port Saint Lucie, FL 34952 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 00005549-128365 REVISION NUMBER: 11 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W /Y LIMITS LTR INSD VD POLICY NUMBER (MM/DD/YYYY) (MM/DDYYY) A X COMMERCIAL GENERAL LIABILITY Y 010035810 12/31/2022 12/31/2023 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE DAMAGE TO RENTED $ 5 OOO X OCCUR PREMISES(Ea occurrence) , MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PECOT- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED I- SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) _ S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 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 HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN CITY OF OKEECHOBEE ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE r•� 2 /16 / f 124 (NLJ) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by NLJ on 04/11/2023 at 10:19PM