HomeMy WebLinkAbout2023 CON National City Host Lions Club - TUP for July 4th Carnival and Fireworks EventSHORT FORM I SERVICES AGREEMENT
BY AND BETWEEN
THE CITY OF NATIONAL CITY
AND
NATIONAL CITY HOST LIONS CLUB
THIS AGREEMENT is entered into is entered into this loth day of June 2023, by and
between the CITY OF NATIONAL CITY, a municipal corporation ("CITY"), and NATIONAL
CITY HOST LIONS CLUB, a service organization "CO TRACT R" .
NOW, THEREFORE, CITY agrees to engage CONTRACTOR to perform the services set
forth herein in accordance with the following terms and conditions:
1. Description tion f Services. CONTRACTOR shall provide services as outlined in
attached Temporary Use Permit, Exhibit "A," for a July 4th Carnival and Fireworks event to take
place from June 30, 2023 to July 4, 2023.
2. Length of Agreement. This Agreement shall not become effective and binding
until fully executed by both the CITY and CONTRACTOR. The duration of this Agreement is
from the effective date through July 5, 2023.
3. Compensation. The total compensation to CONTRACTOR for providing the
services set forth herein shall not exceed a one-time cost of $7,750.
4. Payment Schedule. CITY will make payment within thirty (30) days of signing
agreement. If services are not provided as outlined in Exhibit A, CONTRACTOR will reimburse
CITY $7,750 within thirty (30) days.
5. Termination. CITY may terminate this Agreement at any time by providing one
(1) day's written notice to CONTRACTOR.
6. Inde cdcnt Contractor. It is agreed that CONTRACTOR is an independent
Contractor, and all persons working for or under the direction of CONTRACTOR are
CONTRACTOR'S agents, servants, and employees, and said persons shall not be deemed agents,
servants, or employees of CITY.
7. Insurance. CONTRACTOR shall obtain:
A. El If checked, Professional Liability Insurance (errors and omissions)
with minimum limits of $1,000,000 per occurrence,
B. Automobile insurance covering all bodily injury and property damage
incurred during the performance of this Agreement, with a minimum coverage of $1,000,000
combined single limit per accident. Such automobile insurance shall include owned, non -owned,
and hired vehicles. The policy shall name the CITY and its officers, agents, employees, and
volunteers as additional insureds, and a separate additional insured endorsement shall be provided.
C. Commercial General Liability Insurance, with minimum limits of
$1,000,000 per occurrence and $2,000,000 aggregate covering all bodily injury and property
damage arising out of its operations, work, or performance under this Agreement. The policy shall
name the CITY and its officers, agents, employees, and volunteers as additional insureds, and a
Standard Short Form Agreement Page 1 of 6 City o Nationa.l City and
Revised January 1 National City Host Lions Club
separate additional insured endorsement shall be provided. The general aggregate limit must apply
solely to this "project" or "location". The "project" or "location" should be noted with specificity
on an endorsement that shall be incorporated into the policy.
1. Workers' compensation insurance in an annunt sufficient to meet statutory
requirements covering all of CONTRACTOR'S employees and employers' liability insurance
with limits of at least $1,000,000 per accident. In addition, the policy shall be endorsed with a
waiver of subrogation in favor of the CITY. Said endorsement shall be provided prior to
commencement of work under this Agreement.
If CONTRACTOR has no employees subject to the California Workers'
Compensation and Labor laws, CONTRACTOR shall execute a Declaration to that effect. Said
Declaration shall be provided to CONTRACTOR by CITY,
E. The aforesaid policies shall constitute primary insurance as to the CITY, its
officers, employees, and volunteers, so that any other policies held by the CITY shall not contribute
to any loss under said insurance. Said policies shall provide for thirty days prior written notice
to the CITY's Risk Manager, at the address listed in subsection G below, of cancellation or material
change.
F. Said policies, except for the professional liability and workers'
compensation policies, shall name the CITY and its officers, agents, employees, and volunteers as
additional insureds, and separate additional insured endorsements shall be provided.
G. The Certificate Holder for all policies ofinsurance required by this Section
shall be:
City of National City
c/o Risk Manager
1243 National City Boulevard
National City, CA 91950-4397
H. If required insurance coverage is provided on a "claims made" rather than
"occurrence" form, the CONTRACTOR CTOR shall maintain such insurance coverage for three years
after expiration of the ternn (and any extensions) of this Agreement. In addition, the "retro" date
must be on or before the date of this Agreement.
I. Insurance shall be written with only insurers authorized to conduct business
in California which hold a current policy holder's alphabetic and financial size category rating of
not less than A:VII according to the current Best's Key Rating Guide, or a company of equal
financial stability that is approved by the Cit 's Risk Manager. In the event coverage is provided
by non -admitted "surplus lines" carriers, they must be included on the most recent List of
Approved Surplus Line Insurers "LA SLI" and otherwise meet rating requirements.
J , This Agreement shall not take effect until certificate(s) or other sufficient
proof that these insurance provisions have been complied with, are fled with, and approved by the
CITY' s Risk Manager. If the CONTRACTOR does not keep all insurance policies required by this
Section 7 in full force and effect at all times during the term of this Agreement, the CITY may
treat the failure to maintain the requisite insurance as a breach of this Agreernent and terminate the
Agreement as provided herein.
K. All deductibles and self -insured retentions in excess of $10,000 must be
disclosed to and approved by the CITY. CITY reserves the right to modify the insurance
requirements of this Section 7, including limits, based on the nature of the risk, prior experience,
insurer, coverage, or other special circumstances.
Standard Short Form Agreement Page 2 of 6 City of National City and
Revised January 2021 National City Host Lions Club
L. If the CONTRACTOR maintains broader coverage or higher limits or
both) than the minimum limits shown above, the CITY shall be entitled to the broader coverage or
higher limits (or both) maintained by the CONTRACTOR. Any available insurance proceeds in
excess of the specified minimum limits ofinsurance and coverage shall be available to the CITY.
8. Indemnification and Hold Harmless. To the maximum extent provided by law,
the CONTRACTOR agrees to defend, indemnify and hold harmless the City ofNational City, its
officers, officials, agents, employees, and volunteers against and from any and all liability, loss,
damages to property, injuries to, or death ofany person or persons, and all claims, demands, suits,
actions, proceedings, reasonable attorneys' fees, and defense costs, of any kind or nature,
including workers' compensation claims, of or by anyone whomsoever, resulting from or arising
out of the CONTRACTOR'S performance or other obligations under this Agreement; provided,
however, that this indemnification and hold harmless shall not include any claims or liability
arising from the established sole negligence or willful misconduct of the CITY, its agents, officers
employees, or volunteers. CITY will cooperate reasonably in the defense of any action, and
CONTRACTOR shall ernploy competent counsel, reasonably acceptable to the City Attorney.
The indemnity, defense, and hold harmless obligations contained herein shall
survive the termination of this Agreement for any alleged or actual omission, act, or negligence
under this Agreement that occurred during the term of this Agreement.
9. EMPLOYEE PAYMENTS AND INDEMNIFICATION.
.
.1 PERS Eli i ty -tnclemnification. If CONTRACTOR's employees providing
services under this Agreement claims, or is determined by a court of competent jurisdiction or the
California Public Employees Retirement System ("PERS") to be eligible for enrollment in PERS
of the CITY, CONTRACTOR shall indemnify, defend, and hold harmless CITY for the payment
of any employer and employee contributions for PERS benefits on behalf of the employee as well
as for payment of any penalties and interest on such contributions which would otherwise be the
responsibility of the CITY.
CONTRACTOR'S employees providing service under this Agreement shall not:(1)
qualify for any compensation and benefit under PERS; be entitled to any benefits its under PERS;
enroll in PERS as an employee of CITY; receive any employer contributions paid by CITY
for PERS benefits; or be entitled to any other PERS-related benefit that would accrue to a CITY
employee. CONTRACTOR's employees hereby waive any claims to benefits or compensation
described in this Section 9. This Section 9 applies to CONTRACTOR ACTOR notwithstanding any other
agency, state or federal policy, rule, regulation, law or ordinance to the contrary.
.2 Limitation of CITY Liability. The payment made to CONTRACTOR un ler this
Agreement shall be the full and complete compensation to which CONTRACTOR and
CONTRACTOR' s officers, employees, agents, and subcontractors are entitled for performance of
any work under this Agreement. Neither CONTRACTOR nor CONTRACTOR's officers,
employees, agents, and subcontractors are entitled to any salary or wages, or retirement, health,
leave or other fringe benefits applicable to CITY employees. The CITY will not make any federal
or state tax withholdings on behalf of CONTRACTOR. The CITY shall not be required to pay any
workers' compensation insurance on behalf of CONTRACTOR.
Standard Short Form Agreement
Page 3 of 6 City ofNational City and
Revised January 2021 National City Host Lions Club
9.3 Indemnification for Employee Payments. CONTRACTOR agrees to defend and
indemnify the CITY for any obligation, claim, suit, or demand for tax, retirement contribution
including any contribution to PERS, social security, salary or wages, overtime payment, or
workers' compensation payment which the CITY may be required to make on behalf of(1)
CONTRACTOR, any employee of CONTRACTOR, or any employee of CONTRACTOR
construed to be an employee of the CITY, for work performed under this Agreement. This is a
continuing obligation that survives the termination of this Agreement.
10. Accetabilitv of work. The CITY shall, with reasonable diligence, determine the
quality or acceptability of the work, the manner of performance, and/or the compensation payable
to the CONTRACTOR.
l 1, Business License. CONTRACTOR must possess or shall obtain business license
from National City Finance Department before beginning work.
12. Prevailing Wages. State prevailing wage rates may apply to work performed under
this Agreement. State prevailing wages rates apply to all public works contracts as set forth in
California Labor Code, including but not limited to, Sections 1720, 1720.2, 1720.3, 1720.4, and
1771. CONTRACTOR is solely responsible to determine if State prevailing wage rates apply and,
if applicable, pay such rates in accordance with all laws, ordinances, rules, and regulations.
13. Administrative Provisions.
A. Computation of Time Periods. If any date or time period proi.ed for in
this Agreement is or ends on a Saturday, Sunday or federal, state or legal holiday, then such date
shall automatically be extended until 5:00 p.m. Pacific Time of the next day which is not a
Saturday, Sunday or federal, state, or legal holiday.
B. Counterparts. This Agreement may be executed in multiple counterparts,
each of which shall be deemed an original, but all of which, together, shall constitute but one and
the sane instrument.
C. Captions. Any captions to, or headings of, the sections or subsections of
this Agreement are solely for the convenience of the parties hereto, are not a part of this
Agreement, and shall not be used for the interpretation or determination of the validity of this
Agreement or any provision hereof.
D. No obligations to Third Parties. Except as otherwise expressly provided
herein, the execution and delivery of this Agreement shall not be deemed to confer any rights upon,
or obligate any of the parties hereto, to any person or entity other than the parties hereto.
E. Exhibits and Schedules. The Exhibits and. Schedules attached hereto are
hereby incorporated herein by this reference for all purposes. To the extent any exhibits, schedules,
or provisions thereof conflict or are inconsistent with the terms and conditions contained in this
Agreement, the terms and conditions of this Agreement will control.
F. Amendment to this Agreement. The terms of this Agreement may not be
modified or amended except by an instrument in writing executed by each of the parties hereto.
G. Assignment &Assumption of Rights. CONTRACTOR shall not assign this
Agreement, in whole or in part, to any other party without first obtaining the written consent of
CITY.
Standard Short Form Agreement Page 4 of 6 City ofNational City and
Revised January 2021 National City Host Lions Club
H. Waiver, The waiver or failure to enforce any provision of this Agreement
shall not operate as a waiver of any future breach of any such provision or any other provision
hereof.
Applicable Law. This Agreement shall be governed by and construed in
accordance with the laws of the State of California. The venue for any legal action arising under
this Agreement shall be in either state or federal court in the County of San Diego, State of
California. The CONTRACTOR shall comply with all laws, including federal, state, and local
laws, whether now in force or subsequently enacted.
J. Audit. If this Agreement exceeds ten -thousand dollars 1 , 00 , the parties
shall be subject to the examination and audit of the State Auditor for a period of three years
after final payment under the Agreement, per Government Code Section 8546.7.
K. Entire Agreement, This Agreement supersedes any prior agreements,
negotiations and communications, oral or written, and contains the entire agreement between the
parties as to the subject matter hereof, No subsequent agreement, representation, or promise made
by either party hereto, or by or to an employee, officer, agent, or representative of any party hereto
shall be of any effect unless it is in writing and executed by the party to be bound thereby.
L. Successors and Assigns. This Agreement shall be binding upon and shall
inure to the benefit of the successors and assigns of the parties hereto.
M. Subcontractors or Subconsultants. The CITY is engaging the services of the
CONTRACTOR .ACTO identified in this Agreement. The CONTRACTOR shall not subcontract any
portion of the work, unless such subcontracting was part of the original proposal or is allowed by
the CITY. In the event any portion of the work under this Agreement is subcontracted, the
subcontractor(s) shall be required to comply with and agree to, for the benefit of and in favor of
the CITY, both the insurance provisions in Section 7 and the indemnification and hold harmless
provision of Section 8 of this Agreement.
N. Construction. The parties acknowledge and agree that l each party is of
equal bargaining strength, (ii) each party has actively participated in the drafting, preparation and
negotiation of this Agreement, (iii) each such party has consulted with or has had the opportunity
to consult with its own, independent counsel and such other professional advisors as such party
has deemed appropriate, relative to any and all matters contemplated under this .Agreement, (iv)
any rule or construction to the effect that ambiguities are to be resolved against the drafting party
shall not apply in the interpretation of this Agreement, or any portions hereof, or any amendments
hereto.
111
111
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Standard Short Form Agreement
Page 5 of 6 City ofNational City and
Revised January 2021 National City Host Lions Club
IN WITNESS FIE F, this Agreement is executed by CITY and by CONTRACTOR
on the date and year written below.
CITY OF NATIONAL CITY
By:
A-eting City Manager
(; I " " Trtke4-i rkt,
Date: 130
APPRON LD AS TO FORM:
Barry J. Schultz, City Attorney
Date: r2,/2/1' /1z3
CONTACT INFORMATION
CITY OF NATIONAL CITY
1243 National City Boulevard
National City, CA 91950-4397
Phone: (619) 470-5882
Fax:
Contact: Joyce Ryan
Title: Library & Community Services
Director
Dep.: Library & Community Services
Email: jryannationaIcityca..gov
Standard Short Form Agreement
NATIONAL AL CITY HOST LIONS CLUB
( orp ration — signatures of two corporate officers required)
(Partnership or Sole proprietorship - one signature)
B Ty
(Name)
(Title)
Dat e: r‹:— -y 5
By:
am )
(Title)
Date:
NATIONAL CITY HOST LIONS LLB
P.O. Box 965
National City CA 91951
Phone: (619) 962-9950
Fax:
Contact: Brian Clapper
Title: Chairman
Email: belapper51@gmail.com
Taxpayer I.D. No.: 36-1263962
Page 6 of
City of National City and
Revised January 2021 National City I -lost .Lions Club
EXHIBIT A
WI•N.W.E.11•4414.1.1.11.1•4111,14.19191.141410
V I
CALIFORNIA
Fair/Festival
TUP
City of National City • Neighborhood Services Department
1243 National City Boulevard i National City, CA 91950
(619) 336-4364 u fax 19) 336-4217
mywpnationalcityca.gov
Special Event Application
mood
LlParade/March Lwa1k or Run LiConcerliPerformance
ri Sporting Event other (specify)
Event Name & Location
4
v r TitleNational City Host Lions 76th Annual 4thofJuly Carnival
:
Park
Event Location list all sites bin r nested iirii
Event Times
Set -Up Starts
Date6/27/2023
Event Starts
Date6/30/2023
Event Ends
Date ` / 2 2
Breakdown Ends
'ri :0 m
Time 5
;oopr
Day of Week Tuesday
Day f Week Friday
•04.1•1141MiliMAIVEt
Time 11:59 PMDay of Week Tuesday
Time7:00am-5:00pmDay of Week Wednesday
wawa - wr�ei+vwwri i.}Yw4 ��yY.. Is a a#ri+YVSMh'a.w. t 1FF ..
A * licantIn'r it
Applicant (Your narrte)Brian Clapper
Event Coordinator (if different from applicant)
Sponsoring r i tiro NC LionsCtub
Brian Clapper
f ill Address 113 Belmont Avenue National City, CA 1
Daylho 1 -50
After Hoursi'%
1
094,61‘
Ceti sameFax N/A
com
Public Information h (619)96' 1 .� 1 C P R 5@.
- lritlfAlwaer
Applicant agrees to investigate, defend, indemnify ify and hold harmless the City, its officers* employees and agents
from and against any and all loss, darnaget liability, claims, demandsi detriments, costs, charges, expense (including
attorneys fees) and causes of action of any character which the City, its officers, employees and agents may incur,
sustain or be subjected to on account of loss or damage to property or the loss of use thereof and for bodily injury
to or death of any persons (Including but not limited to the employees, subcontractors, agents and invitees of
each party hereto) arising out of or in any way connected to the occupancy, enjoyment and use of any City premises
under this agreement to the extent permitted by law.
Applicant understands this T/special event may implicate fees for City services, which will have to be paid in the
City's Finance Department hours prior to the event set-up, The undersigned &so understands and accepts the
City's refund �{*L/{ policy for application processing and facility use and that fees and charges are adjusted annually and
are subject t hange
Signature of Applican
Date �/*401f."1�
1
;. CALIFORNIA
NATI NAL IT
ted...
CORPORA
Fair/Festival
TUP
City of National City ■ Neighborhood Services Department
1243 National City Boulevard f National City, CA 91950
(1 )3 6- 3 4•fax (619) 336-4217
www.nationalcityca.gov
Special Event Application
DParadelMarch
Sporting Event
Event Name & Location
rgemitemm
Walk or F u n
oncert/Performance
Other (specify)
Event Title National City Host Lions 76th Annual 4th of July Carnival
Event Location list all sites beingrequested)Kimball Park
(
Event Times
Set -Up Starts
Date 7/ O 3
7:O0arm Tuesday
Time Day of Week
Event Starts 5:00prn Friday
Date 6/ 30t 02 Time Day of Week
Event Ends 1 .00pm Tuesda
Date714J03 Time Day of Week y
Breakdown Ends
7.00am-5:00pm Wednesday
Wednesday
Date7/5/2023 Time Day of Week
c
ru
E
t-
5374
WI 0
> g g
w E-
r '{
to ' S
1
Applicant {Your name) Sponsoring Clapper Sponsoring Organiz tion NC Host Lions Club
Event Coordinator(if different from applicant)
Brian Clapper• e ��`%����9 �$�ri (�
Mailing Address 113 Belmont Avenue National City, CA 91950
Day Phone (619) - After Hours P one arise Cell same N/A
Fax
�
Public Information Phone61g)962-9950 gCL
E-mail l�PPER51@gmaiLcom
Applicant agrees to investigate, defend, indemnify and hold harrnless the City, its officers, employees and agents
from and against any and ail loss, damage, liability, claims, demands, detriments, costs, charges, expense (including
attorney's fees) and causes of action of any character which the City, its officers, employees and agents may incur,
sustain or be subjected to on account of loss or damage to property or the less of use thereof and for bodily injury
to or death of any persons (including but not limited too the employees, subcontractors, agents and invitees of
each party hereto) arising out of or in any way connected to the occupancy, enjoyment and use of any City premises
under this agreement to the extent permitted by Iar.
Applicant understands this TPP/special event may impileate fees for City services, which will have to be paid In the
City's Finance Department 48 hours prior to the event set-up, The undersigned also understands and accepts the
City's refund policy for application processing and facility use and that fees and charges are adjusted annually and
are subject to change. ."
Signature of Applicant;
z
Date
1
Special Event Application (continued)
Please complete the following sections with as much detail as possible since fees and requirements are
based on the Information you provide us.
eesiProceedstRe'ortin
Is your organization a "Tax Exempt, nonprofit" organization? Yes
Are admission, entry, vendor or participant fees required? Yes
If YES, please explain the purpose and provide amount (s):
-444141.01.10444.4,
No
No
f
Sel
$.Estimated Gross Receipts including ticket, product and sponsorship sales from this event,
4o,000 00Estimated Expenses for this event
1 ,000 W t is the projected amount of revenue that the Nonprofit Organization will receive
as a result of this event?
Descri I tion Event
First time event
Returning Event El include site map with application
Note that this description may be published in our City Public Special Events Calendar:
The National City Host Lions CLub will sponsor the annual Independence Day
Carnival and fireworks in Kimball Park from Friday June 30th through Tuesday
July 4th, This event will include carnival rides, food booths, carnival gages
talent shows, youth activities and community displays.
Estimated Attendance
300
Anticipated of Participants:
,coo
Anticipated 4 of Spectators:
Traffic Contro, S.e uric , First Aid and i iUUt
Requesting to close street(s) to vehicular traffic? Yesu No
List any streets requiring closure as a result of the event (provide map)
D Ave between 12th street and 1 th Street
Date and time of street closure: 1_ 7am
0ether(explain)...... ,
Requesting to post "no parking" notices? Yes ii-/1 Nor]
Requested "No Parking" n city streets and/or policing lots (list streets/parking lots) (provide : :
El Other (explain)
Secarit and Crowd Control
Date and time of street reopening: 7/06//2� rr
Depending on the number of participants, your event may require Poke services.
Please describe your procedures for both Crowd Control and Internal Security:
Have you hired Professional Security to handle security arrangements for this event?
Yes If YES name and address of Security National City ii e t
1200 National City Blvd.
••••arawd.r....rdwerdvarRe ~ono al pwinderdedyg.eforl
Security Director (Name)
Police Chief
Phone: (619)3364411
if using the services of a professional security firm and the event will occur on City property, please
provide a copy of its insurance certificate, evidencing liability with limits aft least .1 Million dollars per
occurrence Million dollars aggregate, as well as and additional Insured endorsement naming the City
of National City, Its officers) employees) and agents as additional insureds.. Evidence of insurance must
be provided by the vendor r its insurer to the Neighborhood Services Department at the. time of
submission..
Is this a night event? Yes k No If YES) please state how the event and surrounding area will
be illuminated to ensure safety of the participants and spectators:
City Lighting will be provided. Christiansen Amusements, Incto provide additional Lighting as required
3
First Aid
Depending on the number of participants, your event may require specific First Aid services, First aid
station to be staffed by event staff? Yes ts No First aid/CPR certified? Yes No
.A M
.First aid station to be staffed by professional company, Okb Company __..,...__.,..
If using the services of a professional medical organization/company and the event will occur on City
property, please provide a copy of its insurance certificate, evidencing liability with limits of at least 1
Million dollars per ocurrnc& Million dollars aggregate, as well as and additional insured
endorsement naming the City of National City, its officers, employees, and agents as additional
insureds. Evidence of insurance must be provided by the vendor or its insurer to the Neighborhood
Services Department at the time of submission.
Please describe your Accessibility Plan for access at your event by individuals with disabilities:
Lions Club to utilize access facilities provided by the City, Lions to provide
AAA approved PORT- -POTTIES.
Elements . f •our Event
Setting up a stage? Yes
r!1
1/1
WAAAA
No�
Requesting City"s PA system
Requesting City Stage; if yes, which size? ....._ Dimensions (13x28)
EiApplicant providing own stage .. (Dimon ions)
Setting up canopies or tents?
16 of canopies size c o
15 of tents size . o o
L_
No canopies/tents being set up
4
Dimensions (20x28)
Setting up tables and chairs?
Furnished by Applicant or Contractor
20
20
# of tables
# of chairs
No tables being set up
No chairs being set up
(For City Use Only) Sponsored Events — Does not apply to co -sponsored events
# of tables 1. o tables being set up
# of chairs No chairs being set up
Contractor Name
Contractor Contact Information
Address
Setting up other equipment?
Sporting Equipment (explain)
Other (explain)
City/State
Phone Number
Not setting up any equipment listed above at event
Having amplified sound and/or music? Yes
ry
PA System for announcements
Live Music Ilba
Other (explain)
If using live music or a DJ. 10. Contractor Name
No
CD player or DJ music
Small 4-5 piece live band ►
Large 6+ piece live band
Address
City/State Phone Number
5
Using lighting equipment at your event? '
Bringing In own lighting equipment
Using professional lighting company
No
llow Company Name
Address
Using electrical power? Yes
Using on -site electricity r�
Bringing in generator(s)
No
City/State Phone Number
For sound andfor lighting
Using Kimball Park Bowl
Lighting (from atri_ to 12pr )
For food and/or refrigeration
For sound and/or lighting For food and for refrigeration
Vendor Information
PLEASE NOTE: You may be required to apply for a temporary health permit if food or beverages
are sold of given away during your special event. Also see 'Permits and Compliance' on page
in the Special Event Guide. For additional information on obtaining a temporary health permit,
please contact the County of San Diego Environmental Health at (619) 338-2361
Having food and non-alcoholic beverages at your event? Yes 4/1 No
117
r
Vendors re grin food on -site Business License Issued by City
If yes, please describe how food will be served and/or prepared;
To be 'prepared In accordance with City, Fire and County Health Regulations.
If you intend Jo cook food in the event area please s•eeify the method:
iyeiGAS VLECTR1C
—CHARCOAL
441414014141.04.
OTHER (Specify): �.
Vendors bringing re-ao a ed food 1 Business License Issued by City
Vendors bringing bottled, non-alcoholic beverages(i.e., bottled water, can soda, etc, 1
Vendors selling food # 1 Business License #(s) Issued by City
Vendors selling merchandise ## 1 Business License Ns)Issued by City
Food /beverages to be handled by organization; no outside vendors
Lllvendors selling services Business License #(s)
Explain services
Vendors passing out information only no business license needed)
1► Explain type(s) of information
City Issued info, NC Chamber info
} ---- -= -
No selling or informational vendors at event
Having children activities? Yes
v� NoC
PLEASE NOTE: In the evert inflatable jumps are provided at the event, The City of National City
requires commercial liability insurance with limits of at least Million dollars per occurrenceNlillon
dollars aggregate. In addition, the City of National City must be named as an Additional Insured
pursuant to a separate endorsement, which shall be r avid d by th.e ven.d r . r its Insurer to theCity's
Risk Manager/ along with the Certificate of insurance, for approval prior to the event. The application
should be filed out at least one week prior to the event, For questions or to obtain a copy of the
"Facility Use Application", please contact the Engineering/Public Works Department t (619)
molopoffm
Inflatable bouncer house # .,.W..�..�.....�..W..�.o�...�, Rock climbing wall Height
EllInflatable bouncer slide # Arts & crafts i, ., craft making, face painting, etc.)
Carnival id s
Watermelon eating contest and kids game
1/400er
APIWIMPIMPW
131 No
Having fireworks or aerial display? Yes
Vendor name and license Fireworks America
Dimensions2/.5 inches to inches
Number of shells 1712
Duration 14.2 Minutes to . Minutes
Max, size4 Inches
PLEASE NOTE: In the event fireworks or another aerial display is planned for your event/ The City of
National City requires commercial liability insurance with limits of at least!Million dollars per
occurrence/ $4 Million dollars aggregate. In addition, the City of National l City must be veined as an
Additional Insured pursuant tip a separate endorsement, which shall be provided by the vendor or Its
insurer to the City's Risk Manager, alongwith the Certificate of Insurance, for approval priorpriorto the
event. Depending on the size and/or nature of the fireworks display, the City reserves the riglit to
request higher liability limits. The vendor rust also obtain a fireworks permit from the National City
Fire Department and the cost is $6:02.QO
Arranging for media coverage? Yesn Non
Yes, but media will not require special set-up
Des, media will require special set-up. Describe
4
5
9
Contracting with portable toilet vendor,
Company Phone
Load -in Day & Time Load -out Day & Time 7/5/2023
Event Si *na.e
PLEASE NOTE: For City sponsored or co -sponsored events, banners publicizing the event may be
placed on the existing poles on the 1800 block and 3100 block of National City Boulevard. The banners
must be made to the City's s e lfioatiorrs. Please refer to the City's Special Event Guidebook and Fee
Schedule for additional information,
Are you planning to have si ria a at your event? Yes ri No
Yes, we will post signage # Dimensions
Yes, having inflatable signa e # (complete Inflatable Si ria e Request form)
Yes, we will have banners
What will signs/banners say?
How will signs/banners be anchored or mounted?
Location of bannerslsi page
PLEASE NOTE: one toilet for every 250 people is required, unless the applicant can show that there
are of i ient facilities in the imrnediate area available to the public during the event,
Are you planning to provide portable restrooms at the event? Yes
If yes, please identify the following:
Total number of portable toilets{
Total number of ADA accessible portable toilets:2
Diamond
No
1
Portable toilets to be serviced, OD Time
Daily, AM
Set- •5 Breakdown, Clean- •
Setting up the day before the event?
101
L_
Yes, will set up the day before the event.
No, set-up will occur on the event day
Requesting vehicle access onto the turf?
•
•
of set-up day(s)
Yes, requesting access onto turf for set-up and breakdown (complete attached Vehicle Access
Request form)
No, vehicles will Ioadfunload from nearby street or parking lot.
NPDES-Litter Fence
telf
City to install litter fence
Applicant to install litter fence
N/A
Breaking down set-up the day after the event?
Yes, breakdown will be the day after the event, f breakdown day(s)
No, breakdown will occur on the event day.
How are you handling clean-up
Using City crews
Using volunteer clean-up crew during and after event,
Using professional cleaning company during and alder event.
Miscellaneous
Please list anything important about your event not already asked on this application:
Please make a copy of this application for your records.
We do not provide copies.
CALIF PRIVI
%ATi0NA1i
IN co rat nit xstol
L!p!!ial Event information
Special Events
Pre -Event Storm Water Compliance
Checklist
Name ofSpecial event; National City Host 4th of July Carnival
Event AddAddress:Kimball Park, 12th D AvenueExpected # of Attendees: 25,000
Event Host Coordinator: Brian Clapper Phone 1 r: (619)
�.� � �._.....� _....�.....�.._...
II. Storm Water Best Management Practices (BMPs) Review
YES
NO
N/A
Will
Provide
enough
number
trash
cans provided
of trash
bins:
for the
2V°P.
event?
w,.s�w,Y.w.wyYw.wwrwllyw�
.............e.... ........ 1..1..1�
.
Will
Provide
enough
recycling
number
of
recycle
bins
provided for the
bins:
event'
. / 1
.
I
I:
s
Will all
for ADA
Do all
from
•.+4rr..••Y.+M..rr4rN•..vxrnla..n'..
portable
compliant
storm drains
entering
toilets
___
portable
-.r.............
have
t.Ir..n._.wx.w.xw.ixw.t».x.t....a.x.rrtw.w..i.w.ur.i.,.w....wr4W4....t.w.+.
have
screens
secondary
toilets)
•
to
containment
.... ..wr�,rx�r.►,a..
temporarily
trays?
protect trash
1...-.--.._-_- .- _.-.-
rywuw.a.�u!uu•,+rur,•rim+.Y.'�,WN••.w
(exceptions
.. .. ..
and debris
+..i,{I.o--,�.FI�u,+.-r+.W..•1.
..
_ -
r.. r=..-'.r.=�.rxw.W�.
.1 .. /....F' \ 1 ..
•
•
V . 1
-—...,.ax,«.,,...wnw.►-..:«Iw...yw...w...
.....yr..*y
r
I
M
. N
Are spill
cleanup
.....• ..Kx.A.xw.wwx.xa..w.w...,_mama.
kits
readily
available
at designated
spots?
..Ioh..,iwwx.x,..Kaswa.a..aa ____h..w,r•,y..-. _..-...1..m..
.w/x:ix...w..., wa.w++4uwrw
1
1
V a
I J...•1V1' 11 -Y _-.-_--1N__✓t
.
. . _.«.........a.a.�wx.,.
* A Post -Event Sturm Water Compliance Checklist will be completed by City Staff.
10
City of National City
AGREEMENT
Persons requesting use of City property, facilities or personnel are required to
provide a minimum of $1,000,000 combined single knit 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. The insurance company issuing the
insurance policy must have a A.M. Best's Guide Rating g f A: ii and that the
insurance company is a California admitted company; if not, then the insurance
policy to the issuance of the permit for the event. The Certificate Holder must reflect:
City of National City
Risk Management Department
1243 National City Boulevard
National City, CA 91950
Organization:
tint City Host Lions Club
Person in Charge of Activity: Brian Clapper
113 lr nt Avenue, National City, CA 91950
Address:
Telephone: (619) 962-9950
Date Q r u
As a condition of the issuance of a temporal 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 tt rn y's 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 r its agents, employees or contractors.
Signature f Applicant: -
Official Title: Clan
For Office Use Only
•
Date:74 -#164-
Certificate of Insurance Approved
4CORd
X.
DA1 IklitI»FYY
04/13/2023
THIS CERTIFICATE IS ISSUED 1 MATTER OF INFORMATION NL AND CONFERS NO RIGHTS L'ON THE CERTIFICATE HOL E , THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND4 EXTENDALTER THE COVEIAOE .AFFORDED BY THE POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THEOSSUINO i $ ()t AUTHORIZED
REPRESENTATIVE OR PRODUCER. AND THE CERTIFICATE HOLDER;
7yIMPORTANT: if the
certificate holder
r� i an ADDITIONAL N INSURED, theolil ies) must
be�yendorsed. If y�y �} qUOROGATION
IS WAIVED.
�- 1V D subject to
• e terms and conditions of the p licyt certain policies may require an endorsement. statement t on this r Itl n e does not confer rights to the
certificate holder In lieu of such endorsement
ROOUChit
CERTIFICATE OF LIABILITY INSURANCE
DAP insurance Services, Inc.
1900 E. Gaif Read, Suite 650
Schaumburg, IL 60173
ur1
National City Host Lions
National City, California
:OVERAGES
CERTIFICATE NUMBER,
P119141.,
John Adam
lw lionscitib$OdspiriS.00111 .K•.
f _��w K...iiw...•x.,I w..ri . r.•.Y.v..wjyr�4'� L.Y ��eer. r.-:-.t ..�....� Awn op. i44 4ww1M1MV 4i.,.a .,rr11Ww
AFFOROIN
IIR A : ACE American Insuran
oistmeR 8
INSURER r+ C
III stints r :
COVERAGE
CQEll
FtiW Wr41Y.+�w
fRr
•.Fwr..w,•M4Fi+ww•F.�-._��_....++--.�:r-,..�.�:.�: n'�*+++5iu �•N� ....��xw4+�wx
SORE: F
RE
ThIS TO CERTIFY THAT T THE POLICIES OF INSURANCE A LISTED BELOW HAVE BEEN ISSUED TO THE INSURED
NON:Alto NOTWITHSTANDINCi ANY FIEOUIRMCNT TERM OR CONDITION OF ANY CONTRACT OR OTHER DO
" RTUU=l.' T , MAY BE NitriUt OR MAY PERTAIN THE IIIISURANCE AFFORDED BY THE POLICIES )
EXCLUSIONS AND CONDITIONS tF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
1''1'175-1-egr
P OF ! U HCjuisizu POLICY ti1b)MBEil
r1 11. LIABILITY
_COMMERCIAL, GENES IMAM(
CMS.M7I OCCUR
n rid
is .0,00
y ., M,. Y., t\V.cW,..6k,R,.M..a.N.4+ ely.• m......,.}1wr~41 ..h•w_,...M
t l E Mfl LIMIT APR, 1E8 PER
."X POLICY
rr'OMWL. 1AIT Y
T
ANY AUTO
Y #. OWNECI
1AUTOS
HMO AUTO
Lit �3.
t L LA t\1A
OCCUR
EXCESS LIAO r
.12E0 WrEtiltION
scit igpuixo
Asir
NON-MNED
AT1
'WORKERSj1 COMPENSATION
A$t EMPL L oYERsktIABlittY
Off FROPII.ETORIPARTNERTXECUrra
.• E r1. I 1 t #: L, E C
i IY . ntrat if1 N3{)
]f ; ea, ueKrriiieurtuer
BOO G41351241
15A H1076122,0
#j114Nr,!,c1411d4 tri
as/az/zoxz 09t01l2023
09/010023
OEVAIPTION CIF OPERATIONS, LOCATIONS 1}VellICLES (Anita ACOlati 101Additional Rang ictiedul.. if mom sfo r am)
Provisions of the policy apply to the named insureds participation in the following activity during the poticy period shown above: Annual 4th of July Carnival 2023
The following persons or organizations granting use of real property, Including structures thereon are included as Additional In ur d(s), but only with respect t
General Liability arising out of the use of premises by the insured shown above and not out of the'sole negligence of said additional insured.
*** C i of National City
PROVISIONS N THE POLICY DO NOT APPLY TO THE SALE OR SERVING OF ALCOHOLIC BEVERAGES
EA
!SION NUMBER:
AMED ABOVE FOR THE POLICY PERIOD
WENT WITH RESPECT TO WHICH THIS
REIN IS U TO LL THE TERMS,
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N t
22667
`./1.r/./ rwrnL6�M+rM M �xal ar_+�.�.•.rYf4�1
zamt. i! $ 1;020,.0130
13
NNy55GM,. MIN r IK:.r rtr{+.ry: •n L'+'w /*1`fiM+++M•yl�'•+•A-VY,YLf r�F�'-w•+rn�4l.+w w+µ
GENERAL GAI ' ',OOO"O
PAOCA-V8*COMPiC/PAGE Sl ., OO
b.114 L MU
'h 1}Wi.47C•'.'w�� �i Y ' M-••�i•�•t F+K+rv•nY�i1��.d�+fxf 5.5
VI
KY OVUM( M( (Pet person)
lr l'.
WWI " II.IWRY tPei €i ;rit xf1
11000
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y
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SEASEr . 1>Ct# Y LIMIT
*SrvH�fAy'-�'4N5^rr.Mr.tilr^
CERTIFicAtE HOLDER
CANCELLATION
City of National City Gio Risk Manager
1243 National City Blvd,
National City, California 91950
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE TNERoFi NOTICE WILL6E DELIVEREDIN
ACCORDANCEWITH THE POLICY: RgVi5)4N5.
AUTHORIZED NEM seN TAME
(2 1 /3
t lr 1988v2015 ACORD i P .# AT1QN All MOO reserved.
The ACORD Haas and logo are registered mina of ACORD
ADDITIONAL INSURED • DESIGNATED PERSON OR OFiGANfZIaTION
'1;k4aii-rvid Inure The ITittirnailorial Association of Lions Clubs
ry ..4 wnv.„ _. �.N.. �.. - a...� y,'.,#.. .,�y.,.w,.rw+�rxwwow�r+rww7lP+� w�M*W1ww .+wxl M+*..l.b5 7�14n J q4. fl,u�a.w9L1iremh�n yMwaamnw.-.af ..i,...wr,r.r
$yam �� Nub of Poriod
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ACE American insurance Company
`yyu} ���{y�� 4 y£.�i .yyr�{ry+.aF W+K+�+�awiw+w4,.M�+•i•��.,µ�
23
fr t eye Date of Endoreirnenl
-fl..w ww.1i+. ..--.- .+.•Y+.••-•. •#.ww`+.�rl...F�MYRYwTIi
THIS ENDORSEMENT CHANGES p POLICY PLEASE READ IT CAREFULLY.
THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
Name of Person or Organization; City al' National City, i243 National City Blvd., National City, California 91950
Persons or Organizations granting use of real property, including st tt urethereon„ to a
ed insured.
A. WHO 1S AN INSURED ti 1 is amended to include as an adclitionol insured the person or org,,anization shown
in the Schedule, but only with respect to liability arising out of r operations or prenxikles owned by, used by or
rented to you.
However:
i. The insurance afforded to such additionlil insurod only applies to the extent permittel by law; and
. If coverage provided to the additional insured is required by a contract or agreemont, the insurance afforded to
such additional insured will not be 'broader than that which you are required by the contract or agreement t
provide for such additional. insured.
9 With respect to the insurance " orded to tee additional insureds, the following is acided to Section III- Limits or
insurance!
f coverage provided to the a•lcditi i insrured is rtNuired by a contract or agreement, the, most we will pay on t f o
the additional insured is the amount of insurance:
t# Required the contran or agreement or
Available under the applicable Limits of Insurance shown in the Declarations;
whichever is less,
nib insurance does not 1 to;
1. Any 'occurrence" which takes place after the named 'insured ceases to have use of said pommies or above items.
Structural alterations, new construction or demolition operations performed by or on the person or
organization as describedabove}
. Liability out of the sole negligence of the additional insured.
MS 17
OCrustm 20 16 PM nghis reserved
Pagel of1
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City of Nationa.I City
BUSINESS TAX CERTIFICATE
"for Services Provided In National pity, California only"
Business Name
Business Location
Business Owner(s)
NATIONAL CITY HOST LIONS CLUB
12TH ST
NATIONAL CITY, CA 91950-3316
Ai FIERANGELO
BRIAN CLAPPER
{NATIONAL CITY HOST LIONS CLUB
1 6
NATIONAL CITY, CA 91951
THIS BUSINESS TAX CERTIFICATE DOES NOT PERMIT A BUsINESS
THAT 13 THPRWI F prtrmiiRiPrFn
NATIONAL CITY HOST LIONS CLUB
44, OAb100111fIA
NATIONAL clflp
Business Type
Account Number
Effective Date
Expiration Date
2023
BE PO8TEDIN A CONSPICUOUS PLACE
AND
NOT TIRANSEZRABLE OR ASSIGNABLE
e pt f Non -Profit
09000071
January 01, 2023
December 3112023
As Rtia,f.'....Y
WF
"y Manager
NOTE! IT IS YOUR i:0:l i 1 To. REN5W THIS
CERTIFICATEliSlifiTHER OR NOT YOU RECEIVE A
RENEWAL NOTICE
For all Inquiries mgardIn IiI certificate, contact HdL
Business Tex Support *1, r ea (10) 3 w , 9 .
Thank you for your payment on your National City Business Tax Certificate. ALL CERTIFICATES MUST T BE AVAILABLE FOR
INSPECTION UPON REQUEST. if you have questions concerning your business license, contact the BusinessSupport Center
via email at: NationalCity@HdLgov.com or by telephone at: (1 ) 382...2596
Keep this portion for your license separate in case you need a replacement for any lost, stolen, or destroyed license. A fee
may be charged for a replacement or duplicate certificate.
This certificate does not entitle the holder to conduct business before complying with all requirements of the National City
Municipal code and other applicable laws, nor to conduct business in a zone where conducting such business violates lave
If you have a fixed place of business within the National City, please display the Business • Tax Certificate below in a
conspicuous place at he premises. OthenNise, every Business Tax Certificate bolder not having a fixed tam of business in
the City shall keep the Business Tax Certificate upon his or her per'ori, or affixed in plain view any cart, viet van or other
movable structure or device .at all times if required by the Collector,
Starling January 1, 2021, Assembly Bill 1607 requires the prevention of gender -based discrimination of business
establishments. A full notice is available In English or other languages by going to: https://www.dca.ca.gov/Oblicationsi
N NAL
i
Movem00
BUSINESS TAX SUPPORT CENTER
.8839 NI CEDAR AVE1
FRESNOt CA 93720-1832
NATIONAL CITY HOST LIONS CLUB
PO BOX 986
NATIONAL CITY, CA 91951
City of National City
BUSINESS TA.X CERTIFICATE
Account Number: 09000071
Date of Issue:01101/2023
la 4.4K ad 44411
04/19/202309:13
From:Anderson Professional Business 16194986362
#767 P.001/002
bits:
0. fib doors end aisles must maim usoilistrottedittdi limos; 3 "alc + " rid .
a osset open fron inside wigknowledge,
Bait silos: yew* oxituM to Willow nat pat, miniond"More with %"c
` (pie Nutmeat City Oioarso I 5.21.31,0)*
t BoN oxatlet a allootspairdews rope°+ do Pet FOP am mud boa 0Pa.
j a+ kigas coocestmete sod obi : attic tip. stall.ba vi* i at Ili time.
1 J. Fir Protection System
Stamp no *step b poonittad claw than 34m baler lb sallies (1 *" below sprinkle'. ids)!
•( br Ow coot* be l� t o .
F( .i lh YF i # ;��'�� Ikabek � �1 �.F Age+
4
b autioireithies systems war tervised somigamailyirisfe Sudo Ma Woad
{) i ream It Spriekliv I� e*: ato #un k be Wore� filters,�; �, , miutt kept Glom,
ysieset Ike
Sr Service exthisoiActts): b lidorslai.11e tart' wed l mbar urtlgar in rod,
tr. Provide no settinceishre prwide „- - . "..iireteiskot(t) with a Pitiirzfektini ming Of 2A101304 Mi ,► o-.
Ma t p s) kt a visible kcal* ' to * *teetiosideltot
�. � y� +�p.•+wv . AY E 1 � � 'is � u} oakum' for .+ stogy e,F I� �Y/� ■yrt +
.4--2' ■0 .i.ir�1`���1{{Ai_�•119Y.l."LSo=tit .�++rha+r•rt+iSMWi r tFMwN��.�e,w Wiw`/n +r A.l4 il�<i�L.�jwrwww.*Yr +i xww�xww rt2 .4.N #+Y`I 1��+7 N; ill ai� +�rt� w r ++
CITY 0 !NATIONAL F tIP
Fin DEPARTMENT
1243 Nadal chi Blvd
National City, CA 919504301
Phone 61) 3364550 Fax 1 3364562
Butpri Seed Insxection
3
1. E�i� A141 ot11I0 n �1WV�f� (90 aye Y.
t ` *Wm mid mitt *module capacity (splicing prohibited), repair damaged plug
1 () e. Nuke' *aniooneott: dottiest WW1 justoloft Itea 'Wes, tip mita tow plow
L Cintoit'frtr l Well btrukta Rs Wales citottitc
. I () s. Citclaitbreaker itintifkatilot kketi# cogele chalk Imam aid dot 0 sisetliailam.
( ) Ii. Cat peed aim aeb t denim atw vildiiii tad 7r Mid ieittt . that ai- to at&
1. Pergamettdeatemai must bittgalildbyat Hama erttialen Wet pen*
ki. ND damp i alb % eftiricelmoialaical, boiler. p rooms, Ntitimiain minimise O" el mutt mod
"rYY0..1=1,rt:vulDt."1 .li 4t.-Alf,w r►•r•' � +rw-.7-ta�'[wir.74.1 yV;F'.".,"". 4 .41.1=+r+.+ii.tm.-i"t::• M� M ,,�j*. 1 n! '""`iyp. }.,, w,{ h+u�VN irz 5 ♦ ,... +.`
�. n+^+^"�•• *!'M�rtxHrww ww infix.. 4,rA.+.,..•f++�f ...ri,.� ,�l,Yrtrt+�.M,.� w.��� I5F4w+ti�•.:+++fr.w.1`.e4wYii�:i:�si�.+kw�Y.4VITA
if a fin 111111tOt .
( a. i av04:01004: ittliallan 31011,11- ill wet ad evikily ir4
( } b1 Ceimptiod or INA cue ere ctopty.or foil.
i ' Ca Itla "O.". fibtic Or Illocarg7 temedniat tinottereei tip* seugin, tispil eilriaini, sed thoorstive mettetel U
I be, composed oft master takibiebilt ra Ail be vetted ietb 4.Aga* wardiat
1j�
d, a'ttar fire� �o 15' pleb ail WIN � r b a i,
IL Oiler Ma a simillit raiteriele sung be steed in sued or eta moved eemeiken.
4►►.rtrt441.��,,>HHxx WWlY► t c dieossdo .e w.yWr�est t.$ at a n t t ►ay ,,F1 .,,�,
:t:aMiW z.-+ 44-w..=.wiw 1 * .rv+. ,. ......r ,t42:M�++i•4pl t"'i 41�-+114=. 7d4;, ..*�... .. ,. -%t Vi;i�rit, #44 w+,4=...Lte.pzn i.. tz.- rm t l.s 4-=,�.r, ..r..µ ,4 ►n 1 4
#4M+w.+�Mw�w*'t.•.w,r+w. +•"5{.1RlZl +.+ l.Fr+NN.r�w..r-•*►r,e�nr+rHrl4 �i`..ilyY;naS•�,,..rni.��.+,{*,LrM '14++11�.I,wfiMhlA
e ks1 '
th ovemoveSent o#.. 'moved s :., � . hazardous
:Si.:n�: ls neat br: apolabelled perfit Widen of CP.
ItaaktriNso 4
*omit afibsioesa�
Chaim ofloadlets Adilmet
RUC atotilcIteetrosoY;
ems)c Bow Lk.I Pereette NCNIC 64446.1 CFC 1 c Yip
wet
Lbba''oUct eY.
CliptiCOM
Alarm
Sprinkler
Private ► 1l drip
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1
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Quartesi
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+,•+•r"+••M*"I h/.iFr•al+•H,1i,:4�xYrL.rrSWix 4r,,.+wwr.i,....•Nh•W44W.a%�4M..,...��rw.'i},p•s+,-�.HYF. #11 �4`I'rFfkM'+Y�+•�++.�r7�ihY-4 �nlnri rti„•+.
Access:.
Street tru beer Fiala ba V1116111 fvc to " 1 6 1 *''` ! I " io Wit, comnietios colas.
bR protiotiee t , der eines, pcter`s tea yam,
In+rtar'I+e, 0341kir wants, fin WainValthadi t
y •+r AS•lriAY•7i1111 Mal:14M'antiala.,":41='.r'.. :.w` � `Y.-:.pia.' '“..rca --4.. rogialI+Y bocurIrtnelt,h Y :4=4,.w...r ==,-*r�.�xl,ww...,i„m...4k�1,74'M014-+J+ir�Fl+wl�.ran w rnl t:44,,
i w,�wwiwl.l w•r•-•r+vir .w.4f5...Y.'•.rfil +.n.m4�
CPC 565.1
CYC 601.14 509.2
CPC M 111418
CPC 1.111.1.1
MC W
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From:Anderson Professional Business 16194988362
Part
Park
Park
City
Park
Prk
Part
Part
1
3
A
Veri
I ver
from
Pert
2
PART
Certifi
Addre
Pilate
Silt
+ STATE OF CALIFORNIA
D A# 1 ME T p HO 5ING .NO ocomuNire DEVELOPMENT
QiV1. roN OF CODES AND STANOARDS
PRIVATE FIRE HYDRANT TEST AND CERTIFICATION REPORT
PARKS MUST RETURN THIS FORM TO THE ENFORCEMENT AGENCY' FOR THE PARK
SEE THE REvERSE SIDEFOR INSTRUCTIONS ON COMPLETINGTHIS. FORM)
ATIOm
Para . LW Mobilo Fna
• ANNUAL
*tandpOes
drant ste
hydrant t
here subje
!lurid by
hydrtts
artdpipeo
tch hydran
1 'I 1,4I
Alt.
Part
Agen
Bad
RRD
ur
testis reel
rl4
.-CERTIFIC
Narteiit
622 FkON
lie •Numbs
Name Fa
More M
1 Valley Road
e ProNtssional Busman Sous
ress and City 119 o Hirway 01, Lakeside. CA 9204D
Park It* 374717
Phone Number (elm G'0$6
VON EXCEPTIONS 7 You do .not roc ceittecetion, but must gale this iection If any of the following applies
0.10(4 owned and maintained 1- Water Company Name'.......
park was built byre September 1,1 - List Date of Construction
park has 14 Or less total lots Enter Numbei of Lots . .
rants and park was built after September '.1 8 Specific (=option at the time of construcbom)
IRE 14YDRANT.OPERATIO.N TEST
re consider hydrants for these ire ,$)
end vales operate fully,. fly. and are properly lubricated
ads and caps are undamaged
to vehicular damage. hydrants are physically protected.
rants is a minlmurnof 36 inches of unobstructed access
tlets. are 14 inches to Inches above grade.
ets need not be a. specific height,. but gust be readily .a a lbte
clearly identified or marked
hydrant has an approved hose in a Marked enclosure
verification blithe Appropriate column)
yes NO CORREGIED
==, wawa
I answers are violations and will prohibit the issuance of the earl( Permit to Operate.
Katy of perjury that either this park is exempt —.
irements or the h &ant operation is in compliance
R FIRE . HYDRANT WATER FLOW TEST
Flow Pressure
(GPM) (PSI)
4
5
6
Park owner Or • erator
To be completedby authorized certifier ONLY*
Barrel Stze Flow Pressure
(deg) R I (PSI)
FOR MORE THAN 6 HYORANTS l THE PA , At"rA N AN ADOrr1 NALr UST USING. THE FORMAT
41:31,10)43ALLoNs Pen MiNUT . iP ) - Rom. PEA IN Poulos P sot/mg hot
ON Off" TM RESULT
WATCH
ainirmoimppieftim
License Clean and No, cie473r573
t
ail Address
Title 'meow_
FIREWATcHFIREEQuiP CONt
Date of Test 91i7 023
OR CONTINUED USE OF EXISTINO SYSTEM •-TO MOWED BY LOCAL FIRE AGENCY ON ,
Title - - -
Sido I
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