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HomeMy WebLinkAboutTUPType of Event: _ Public Concert Parade _ Motion Picture Event Title: Fair _ Demonstration _ Grand Opening 5a-Pe S tovvttMee _ Festival 'd Community Event _ Circus _ Block Party Other `›OtVvl Event Location: Opeecif(.'✓t cotaviAl/tavi a 't( 1-1i011of AV.ev%lrte Event Date(s): From 511 / t to 511 I t I Total Anticipated Attendance: Month/Day/Year ( Participants) Actual Event Hours: t 1 /pm to 3 am(0 ( Spectators) (�i Setup/assembly/construction Date: 6111 1, Start time: " 00P�VI'1 Please describe the scope of your setup/assembly work (specific details): CAGt (S( c�eeo^MtO✓IS Dismantle Date: 1114( Completion Time: c" ` 30 amt List any street(s) requiring closure as a result of this event. Include street name(s), day and time of closing and day and time of reopening. Sponsoring Organization: ©(p .e AA" O✓t C a vti A ..VA "'1 t vtC. Chief Officer of Organization (Name) 1- Off, ( S Or ✓l vla V1 Applicant (Name): T t QV\ 1 kVA d'\ ( O or Profit Not -for -Profit Address: � L� ( E-1 i t4 (A, o A t!Q v Vl e Daytime Phone: (b(6I )N17-yy5( Evening Phone: ( ) Fax: (t.(q) `fiy-y 5/'-( Contact Person "on site" day of the event: l O Sovt tJ AV 6 v to Pager/Cellular: ( t (1-1 0 - (713 NOTE: THIS PERSON MUST BE IN ATTENDANCE FOR THE DURATION OF THE EVENT AND IMMEDIATELY AVAILABLE TO CITY OFFICIALS eWtae 1 '. j aV a V V 0 0 O p4 v o., t of S 14V1 at, ('L'` (it 0 v. Is your organization a "Tax Exempt, nonprofit" organization? ✓YES NO Are admission, entry, vendor or participant fees required? _ YES NO If YES, please explain the purpose and provide amount(s): $ Estimated Gross Receipts including ticket, product and sponsorship sales from this event. $ Estimated Expenses for this event. $ What is the projected amount of revenue that the Nonprofit Organization will receive as a result of this event? Please provide a DETAILED DESCRIPTION of your event. Include details regarding any components of your event such as the use of vehicles, animals, rides or any other pertinent information about the event. _ YES NO If the event involves the sale of cars, will the cars come exclusively from National City car dealers? If NO, list any additional dealers involved in the sale: 2 _ YES /NO Does the event involve the sale or use of alcoholic beverages? DYES _ NO Will items or services be sold at the event? If yes, please describe: krtvlatrs wt(4.5( VvIe✓•chAnd s e _ YES " NO Does the event involve a moving route of any kind along streets, sidewalks or highways? If YES, attach a detailed map of your proposed route indicate the direction of travel, and provide a written narrative to explain your route. YES _ NO Does the event involve a fixed venue site? If YES, attach a detailed site map showing all streets impacted by the event. _ YES _ NO Does the event involve the use of tents or canopies? If YES: Number of tent/canopies Sizes NOTE: A separate Fire Department permit is required for tents or canopies. / _ YES V NO Will the event involve the use of the City stage or PA system? In addition to the route map required above, please attach a diagram showing the overall layout and set-up locations for the following items: ➢ Alcoholic and Nonalcoholic Concession and/or Beer Garden areas. ➢ Food Concession and/or Food Preparation areas Please describe how food will be served at the event: If yo intend to cook food in the event area please specify the method: GAS ELECTRIC CHARCOAL OTHER (Specify): ➢ Portable and/or Permanent Toilet Facilities Number of portable toilets: ' (1 for every 250 people is required, unless the applicant can show that there are facilities in the immediate area available to the public during the event) ➢ Tables and Chairs ➢ Fencing, barriers and/or barricades ➢ Generator locations and/or source of electricity ➢ Canopies or tent locations (include tent/canopy dimensions) ➢ Booths, exhibits, displays or enclosures ➢ Scaffolding, bleachers, platforms, stages, grandstands or related structures ➢ Vehicles and/or trailers ➢ Other related event components not covered above ➢ Trash containers and dumpsters (Note: You must properly dispose of waste and garbage throughout the term of your event and immediately upon conclusion of the event the area must be returned to a clean condition.) Number of trash cans: ) Trash containers with lids: Describe your plan for clean-up and removal of waste and garbage during and after the event: SckeAvtlec rvvyttv4€i Pfaff ac).e�,Cy +� 3 Please describe your procedures for both Crowd Control and Internal Security: we 1"4ve cov k\:",,eGt Soto Corps o-c` Sciv, D o --o pr-c)vi"G{.E a"\ apprOprt:-Pcte 4V'0k(44 '5e(t4I' fy CJVatdls 1YES _ NO Have you hired any Professional Security organization to handle security arrangements for this event? If YES, please list: Security Organization: 1010 C- or? S 0-0 Savi lei en D Security Organization Address: Security Director (Name): 14'01 14 014 to Phone: (0(°1- i-I39- )ci-IL4' _ YES ✓NO Is this a night event? If YES, please state how the event and surrounding area will be illuminated to ensure safety of the participants and spectators: Please indicate what arrangement you have made for providing First Aid Staffing and Equipment. O LA v` p y c at r -e C.. tr ' C \Ai 14 toe i v ©p e (p erf,',7e'l atAsei'V S oC4r -P; rs-1- ofiof cev-Etr, Please describe your Accessibility Plan for ccess at your event by individuals with disabilities: WL wit( r,eS.ei've av\r4 c(ei.rty v'i Pk vcsc(b(e yv k4v 1/c wi4k d(5'�,- (1f1e6 Please provide a detailed description of your P� ARKING plan: t w o 5l01.e t ©T5 Old' e c e(/lc`Cg4ec -Vfll- loCCAeo ov, 9 ' Qs+, v evtd-ot 341-1 Please describe your plan for DISABLED PARKING: !� W e ctr e- rt.s4, J� v 1 h n 0 vi d` �4-W-f44 -' rQ �j (4, (ot d` haul r' c o p pov .(c.n -Oor A'hse w:4k G%c5i-1--cfeS 4 Please describe your plans to notify all residents, businesses and churches impacted by the event: NOTE: Neighborhood residents must be notified 72 hours in advance when events are scheduled in the City parks. YES _ NO Are there any musical entertainment features related to your event? If YES, please state the number of stages, number of bands and type of music. Number of Stages: k Number of Bands: Type of Music: cove-kew►Pv("ct % YES _ NO Will sound amplification be used? If YES, please indicate: / Start time: i e/pm Finish Time 3 am/e YES _ NO Will sound checks be conducted prior to the event? If YES, please indicate: Start time: '1.0 am 'pm Finish Time k0'• 30, r pm Please describe the sound equipment that will be used for your event: 1-1 - Spe(i-li✓' v vcv i-ttI`S a- WutAiCS' _ YES " NO Fireworks, rockets, or other pyrotechnics? If YES, please describe: ✓ YES _ NO Any signs, banners, decorations, special lighting? If YES, please describe: t-- L c a o koc1tAh er i- a-1 )( 8 oavitAei' Revised 08/10/05 5 Event: ,for Office 'Use Only Department Date Approved? Yes No Initial Specific Conditions of Approval Council Meeting Date: Approved: Yes No Vote: Kathleen Trees, Director Building & Safety Department 6 City of National City PUBLIC PROPERTY USE HOLD HARMLESS AND INDEMNIFICATION AGREEMENT Persons requesting use of City property, facilities or personnel are required to provide a minimum of $1,000,000 combined single limit insurance for bodily injury and property damage which includes the City, its officials, agents and employees named as additional insured and to sign the Hold Harmless Agreement. Certificate of insurance must be attached to this permit. Organization OpQJ'e,\-(rave Avl Person in Charge of Activity 145 O V) IV A V4 e Address L-1,( --t(j / (iL-, o A kte (A. (4£ Telephone c° t °t - 911- 1 ( Date(s) of Use 5 t 1 / 1 HOLD HARMLESS AGREEMENT As a condition of the issuance of a temporary use permit to conduct its activities on public or private property, the undersigned hereby agree(s) to defend, indemnify and hold harmless the City of National City and the Parking Authority and its officers, employees and agents from and against any and all claims, demands, costs, losses, liability or, for any personal injury, death or property damage, or both, or any litigation and other liability, including attorneys fees and the costs of litigation, arising out of or related to the use of public property or the activity taken under the permit by the permittee or its agents, employees or contractors. (A,04v\rw°v''y9 Signature of Applicant P'ratc‘CDo `f'd vlo+or- I (i it Official Title Date For Office Use Only Certificate of Insurance Approved Date 7 Non-profit organizations, which meet the criteria on page v of the instructions, will be considered for a waiver. If you would like to request a waiver of the processing fees, please complete the questionnaire below. 1. Is the event for which the TUP is sought sponsored by a non-profit organization? /Yes (proceed to Question 2) No (Please sign the form and submit it with the TUP Application) 2. Please state the name and type of organization sponsoring the event for which the TUP is sought and then proceed to Question 3. Name of the sponsoring organization flp a (4'1 Ltd i , JGi c Type of Organization Cc✓vl IAA CA.v\ 4 kA(4L► C-evt-ie(!' (Service Club, Church, Social Service Agency, etc.) 3. Will the event generate net income or proceeds t the sponsoring organization? Yes (Please proceed to Question 4) No (Please sign the form and submit it with the TUP Application) 4. Will the proceeds provide a direct financial benefit to an individual who resides in or is employed in the city, and who is in dire financial need due to health reasons or a death in the family? Yes (Please provide an explanation and details. No (Please proceed to Question 5) 8 5. Will the proceeds provide a direct financial benefit to city government such as the generation of sales tax? Yes (Please provide an explanation and details. No (Please proceed to Question 6) 6. Will the proceeds provide a direct financial benefit to a service club, social services agency, or other secular non-profit organization located within the city such as Kiwanis, Rotary, Lions, Boys and Girls Club? Yes (Please provide an explanation and details. 0Pi,"0At.0N No (Please proceed to Question 7) 7. Will the proceeds provide a direct financial benefit to an organization, which has been the direct recipient of Community Development Block Grant (CDBG) funding? Yes Year funds were received: Funds were used to: Signature No (P lease sign the form and submit it with the TUP Application) 9 3(3 ILI Date ACCORD CERTIFICATE OF LIABILITY INSURANCE GATE (MWDD/YYYY) 3/3/2011 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 pollcy(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 John L. Raya Ins Agency 401 South Mission Drive(91776) P. 0. Box 728 San Gabriel CA 91778 INSURED Operation Samahan Inc 2835 Highland Avenue Suite C National City CA 91950 CONTACT NAME: Producer COM P C.112.Ex+r (626) 570-8611 EMAIL ADDRESS: FAX No): (626)201-2972 PRODUCER p0000463 CUSTOMER ID 0 INSURER(S) AFFORDING COVERAGE INSURER A:Nonprofits Ins Alliance of CA INSURER B : NAIL a INSURER C: INSURER 0: INSURER E: INSURER F : COVERAGES THIS INDICATED. CERTIFICATE EXCLUSIONS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS MR TYPE OF INSURANCE INSR WV0 POLICY NUMBER POLICY EFF IMWOD/YYTY1 POLICY EXP tMWO Y1 LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 1 X COMMERCIAL GENERAL LIABILITY D AZ'aE TO RENTEtf— PREMIS€S (Ea occurrence) $ 500, 000 A I _ I CLAIMS -MADE n OCCUR X 201018073NP0 9/20/2010 9/20/2011 MEOEXP(Myone person) $ 20,000 1 J PERSONAL 8 ADV INJURY $ 1,000,000 :—i GENERAL AGGREGATE $ 2,000,000 CEENL AGGREGATE UMIr APPLIES PER: PRODUCTS - COMP/OP AGG $ 2 000, 000 X I POLICY n JEC LOC , $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ ANY AUTO IEa at adent) ALL OWNED AUTOS BODILY INJURY (Per person) $ SCHEDULED AUTOS BODILY INJURY (Per accetent) $ -- PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON -OWNED AUTOS $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS -MADE AGGREGATE _ 5 — DEOUCTIBLE $ RETENTION S $ WORKERS COMPENSATION WC STATU- i OTH- ANO EMPLOYERS' LIABILITY Y I N U 8Y LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER OCCLUDED? N IA E.L EACH ACCIDENT $ _ - 'Mandatory In NH) I} yas, desaibe under E L DISEASE • EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below I DESCRIPTION OF OPERATIONS / LOCATIONS! VEHICLES (Attach ACORO 101, Additional Romarka Schodulo, U moro apace Is roqulradl 2841 Highland Ave., National City CA 91950 Community Health Fair FICATE HOLDER CANCELLATION City of National City 1243 National City Blvd National City, CA 91950 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 4IZEO REPRESENTATIV �. nne E Raya ACORD 25 (2009109) INS025 (200909) ©1988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD FESTIVAL LAYOUT EXECUTIVE OFFICES ARTS & GAMES AREA TEEN CENTER FOOD AREA BOOTHS & TABLES REGISTRATION PRE - REGISTRATION N.l z 5knl a v A v.e Yoke 10 SAVE THE DATE! Saturday, May 7th Safe Summer Slam (S3) is National City's community building event and youth empowerment festival featuring a health fair, booths, games, entertainment and food. S3 is FREE to the public. Our main objective is to provide over 200 youth with an event designed to promote a safe and healthy summer while increasing their awareness of socially related issues that may impact them such as teen pregnancy, Sexually Transmitted Infections (STIs), environmental awareness and health promotion. Safe Summer Slam has opportunities for: *Non-profit informational tables *Performers (bands, singers, MCs, etc.) *Volunteers and interns *Corporate sponsors *Commercial vendor booths *Youth dance crew contestants *Community partners (for planning) *Individual donors Visit www.safesummerslam.org to check out pictures from past events. Stay tuned as informational packets will be available for download in the near future. To get involved please contact Jason Navarro, Program Coordinator, at jnavarro@y2ycenter.org or 619-477-4451 x605. (5) OPERATION SAMAHAN www.operationsamahan.org www.facebook.com/OperationSamahan www.twitter.com/Y2Y_Center www.myspace.com/OperationSamahan Funded in part by the California Department of Public Health Grant 05-45334.