2023-08-01 IV. B. Exhibit 1 • •
Exhibit 1 Page 1 of 3
08/01/2023 Revised 3/5/19
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CITY OF OKEECHOBEE
55 SE THIRD AVENUE
1 OKEECHOBEE, FL 34974
Tele: 863-763-9821 Fax: 863-763-1686
• ' PARK USE AND/OR TEMPORARY STREET/
SIDEWALK CLOSING
PERMIT APPLICATION
Date Received: - t J Date Issued: _ 1
Application No: a3- o' Date(s) & Times of Event: _(;ep7 3 qr�1� 50-010 I D. pin
- €1)T e - 3 Pi
Information:
l Orgarfra on: Ul<eee E`1&t e(' /lA o
MailingAddress: ///' /if d S7'- ace_3ea '1C )'Le, FL 31497 a
Contact Name: _ y� ' ecki1es )�I Me 2.
E-Mail Address: e Ely;t>ci;' 1 Y114 r n; S tcLe J , LlAg
Telephone:
Work: 63- 7 - L I Home: J I Cell: I g403-5 3a- 1-..54 I
Summary of activities:
(i hc.,12 e' 1 tl-N d IDA e>+4T1 e 11) i to L �1--s \)C.1 .
\i/4—?0 > OCd OJ ice. t:'`� 11)63) ) ,CLS Pe TO) i7ieS CEe
6lt A.)1 1 0
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Proceeds.usage:
Pre_ey/.e6 s c ppc: 011-4 S ree Q't PN;(_J p --Lyject
o ; - 6 - Ckke(_- h )- =e .
Please check requested Parks:
Flagler Parks: ❑ City Hall Park ❑ #1 Memorial Park ❑ #2 #3 X #4 ❑ #5 ❑ #6
[Park 3 is location of Gazebo. Park 4 is location of andstand]
(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 III:
• •
Page 2 of 3
Revised 3/5/19
TEMPORARY STREET AND SIDEWALK CLOSING INFORMATION
(Street Closings require City Council approval. Meetings 1st& 3rd Tuesdays but subject to change)
vai vat
Address of Event: F"aJ me PFeYS - t► tUu� 1 �1 tY q fife c hobe-
Street(s)to be closed: $W.. rf 13"Je. Pt S LJ eJ se be±EEC nu.)-11-0 PP a' ST.
Date(s) to be closed: aN � 5(� -r 3 . c T3 d'117Ay ')i- 4, a 3
Time(s)in be closed: tchA p4t 3 @ 5: CO t'r ) inD4 t LiL �'co Pm
Purpose of Closing: e9 N r op_ s cg.. Vcxd.�-O.L.,s -nQ e f dsT"C'.7 fl 1
Attachments Required for Use of Parks Attachments Required for Street/Sidewalk Closings
► Site Plan ► 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 cif non-profit status ► Original signatures of all residents,property owners and
business owners affected by the closing.
► State Food Service License if>3 days_ 1 State Food Service incense 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.
► ATo alcoholic besre ages 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 applicasnt 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.
• •
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, colerning the use and the rules of using City property, that the information is correct, and that I am the
duty authwized agent of the cvganizaxian. I agree ro conform with, abide by and obey all the Mes 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 Tr st if closing streets or sidewalks.
Applicant Signature Date
••••OFFICE USE ONLY""
Staff Review
Date: `Ii! I Z
Fire Department:
Building Official: Date: 7•f7.23
t '
Public Works: ����% Date: 7 Z3
Police Department: 1 '� Date: 7/7/ Ps
i }
BTR Department: <� --�c � �-- Date: 77J,�}--7,..
City Administrator: Date: 7-2/1 ?- -)
City Clerk: Date: 1 lI jai
I
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 8 -3.3
Date
Temporary Street and Sidewalk Closing reviewed by City Council and approved
Date
Ne3of (�
• •
CITY OF OKEECHOBEE FIRE DEPARTMENT
APPLICATION FOR SPECIAL EVENT
Application Number: JJ Date Received:
NAME OF EVENT: LF)t 2iI 1 V f L °i- c
ADDRESS OF EVENT: FF Ag)e c�i�c_s ? cI FI(:u)i 70
DESCRIPTION OF_EVENT:
69 `L�} A� / 1 C571\ia�- (-Jl C 1 1 0 t :� K A-t�-.� S d 1. �F 4S I I� d f c•J VC t,Does ,
R9-12_1 16C_ i /(:.\ CA E\k l\ ,
NAME OF SPONSOR ORGANIZATION: e h t; ;E e r A i l\1 StP_E€± ri\J I
Contact Numb' before and during event OF RESPONSIBLE PERSON: 663 '�3Q -
RESPONSIBL _PC�RSON'S
1 flR of.) (' �11e IC)1 e ?
DATE(S) AND TIME(S) OF EVENT:
Date: Q- `/- a:-3 Starting Time: ►� t'' Closing Time: 3 prm
Dste: Starting Time: Closing Time:
ARE ANY ROADWAYS TO BE BLOCKED/CLOSED? Yam LOCATION.5(tJ 3 i c f V / cam; iit ) A\ie•
Will Emergency Apparatus(Fire and Ambulance)have access to area?
IF NO,THEN (provide alternatives):
WILL ELECTRICITY BE USED? YES CI Q 0 0 circle)
Locations:
Provided By:
WILL HEATING/OPEN FLAMES FOR FOOD BE PROVIDED? (circle)YES I] 'i7NO (]
Type of Hr-eating Equipment Used:
WILL A TENT BE ERECTED? (circle) YES C
Tent Manufacturer: Size ire-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)
O Tents/canopy fire rating certificate required.
O Tent Size require life safety inspection (900 square feet or less then no permit is required)
O Floor plan /seating/setup drawing required showing exits, etc.
O Emergency access must be maintained. (REFERS TO VEHICLES AND EQUIPMENT)
Li Fire extinguishers must have current tag,and be operational and readily accessible_
O Cooling requires LPG outside of tent pointing away from exposures.
O Electrical wiring exterior rated, not overloaded.
O Fire Services inspection required.
u Fat~w--arch or inspect-ors)REQUIRED? FIRE WATCH Amount:
O Firefighter/Inspector Amount: Li Other:
FIRE DEPARTMENT OFFICIAL(PRINT):
SIGNATURE: -Please call the-FD at 863-467-1586 bor any questions.
Pi, } . ic Revised 11-6-19
• •
OKEEMAI-01 MBUCHANAN
'`���r) CERTIFICATE OF LIABILITY INSURANCE DATiis/2o23 Y�
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 k CT
Lawrence Insurance Agency,Inc. lac,No,Exf):(863)467-0600 I(AAicx,No):(863)467-5142
P.O BOX 649
Okeechobee,FL 34973 marlenetlawrenceins.com
INSURER(S)AFFORDING COVERAGE NAIC C
INSURER A:Mt.Vernon Fire Insurance Co
INSURED INSURER B:
Okeechobee Main Street INSURER C:
111 NE 2nd Street INSURER D:
Okeechobee,FL 34972
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POUCIES 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.
I INTR TYPE OF INSURANCE 1NsQ'yip I POLICY NUMBER (MMIDDNYYYICY Y) IM�YYYYYY) LIMITS
A X (COMMERCIAL GENERAL LIABILITY 1,000,000
EACH OCCURRENCE $ _
CLAIMS-MADE X J OCCUR X BP2662480E 10/26/2022 10/26/2023paEGMIG $(E RENTED nc s s 100,000
X Directors&Officers MEDEXP(Any one person) $
5,000
PERSONAL 8 ADV INJURY_ $ 1,000A0
GEN'L AGGREGATE LIMIT APPIJES PER: GIRIERAL AGGREGATE $ 1,000,000
X I POLICY 1. 8O- LOC PRODUCTS-COMP/OP AGG S
OTHER: tCf Hired/Non Owned Included
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO BODILY IN.J,JRY(Per person) $
MS
ONLY AUTOS SCHEDULED BOGEY INJURY
(Per an0 I$
AUTOS ONLY AUTOV _ acddentlAMAGE
UMBRELLA LIAR I OCCUR EACH OCCURRENCE
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED I I RETENTIONS I $
AND EMPLOYERS LIA TLx'ITY .._.._$STATUTE. J_
QANNYICROMEIETOR EXCLUDED?AT /EPROPRIETOR/PARTNER/EXECUTIVE V(N NIA E.L.EACH ACCIDENT S
(Mandetury In NH) E.L.DISEASE-EA EMPLOYEE$
If yes,describe under
DF.ir'RIPTION 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)
City of Okeechobee and RE Hamrick is included as additional insureds with request to General Liability Coverage
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Cityof Okeechobee THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
66 S.E.3rd Avenue
Okeechobee,FL 34874
AUTHORIZED REPRESENTATIVE
ACORD 26(2018/03) ®1988-2016 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD 5
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