tab 3 - palmettodocsonline.palmettofl.org/.../city/2008/021808/commission/tab03.pdf · tab 3....

SPECIAL FUNCTION PERMIT APPLICATION

EVENT NAME EVENT DATE 3 d 6

APPLICANT S r C 55 1tJ EVENT TIME I n1 PADDRESS j I AUe 3 rChp PHONE

CONTACT ci 4 0 p h PHONE a c I

Ifa temporary restroom is utilized for a period greater than five 5 days a Temporary Use Permit is requiredApplication is available at City Ha11

TEMPORARY RESTROOM FACILITIES ofunits of daysProposed locations

INSURANCE REQUIREMENT Organized events open to the public require insurance naming the City ofPalmetto as an Additional Insured and the insurance policy must be provided to the City Clerk ten10 daysprior to the event If you have entered into a rental agreement for a City facility for a private event noinsurance is required Please review Exhibit A for insurance coverage requirements

The Special Function Permit Application must be submitted to City Commission for approval at least 30 daysprior to the event Sale or consumption of alcoholic beverages on City property is strictly prohibited If yourevent will include the use of loudspeakers you may be required to apply for a Special Permit Exception to theCitys Noise Ordinance See Chapter5Amusements of the City of Palmetto Code of Ordinances

THISPORTION OF THE PAGE INTENTIONALLY LEFT BLANK

PLEASE CONTINUE TO PAGE 2

CITY SERVICES REQUIREDPOLICE Streets Blocked Traffic Control Security OtherPUBLIC WORKS Barricades Cleanup Setup Other

Special Function Permit ApplicationPage 2

Event Date 3 p j U

INDEMNITYi I I ssitlG1mQ TTc YliI33 CQ orntt Permittee agrees to defend indemnify and hold harmless the CITY OF

PALMETTO its officers agents employees and volunteers from all loss cost and expense arising out of anyliability or claim or liability for personal injury bodily injury to persons contractual liability and damage toproperty sustained or claimed to have been sustained arising out of activities of the Permittee or those of any ofits officers agents employees licensees or invitees whether such act is authorized by this permit or not andPermittee shall pay for any and all damage to the property ofthe CITY OF PALMETTO or loss or theft of suchproperty done or caused by such persons CITY OF PALMETTO assumes no responsibility whatsoever forany property placed on the premises Permittee further agrees to waive all rights of subrogation against CITYOF PALMETTO The provisions ofthis pazagraph clause do not apply to any damage or loss caused solely bythe negligence of the CITY OF PALMETTO or any of its agents or employees

I HAVE READ AND UNDERSTAND THE ABOVE SPECIAL FUNCTION PERMIT APPLICATIONCONDITIONS AND INDEMNITY

Permittee

CITY APPROVAL

Public Works Director

Risk ManagementPazks Denartment

Police Department

North River Fire

APPROVED BY COMMISSION

Internal use onlyDate Received

Date

Date

Date

Date

Date

Date

Feb 08 09 1152a Antoinette Kilgore

SpecialPunctian Permit ApplicationPage 2

IEVENTtC p ICt t

t941 7234930 pl

Evsnt Uaee fl Li

IYDE1IIVITY

ssaJCp11Q1ilt aotmPermittee agrees to defend indemtlify and hold harmless the CITYOrPALMETTO its officers agents employees and volunteers froth al lass rnst and expense arising out of anyIiabiliN or claim or liability for persona injury bodily injury to persons contractual liability and damage toproperly sustained or claimed to have been sustained arising out ofactivities of the Ycrmittee or those of any ofits officers agents employees licensees or invitees whether such act is authorized by this pemut or not andPermiitec shall pay far any and all damage to the property of the CITY OP PALME1IOor Loss or theft ofsuchproperty done ar caused by such persons CITY OF PALMET1O assumes no responsibility whatsoever forany property placed on the premises Permittee further agrees to waive atd rights ofsubrogation against CITYOF PALMETTO The provisions ofthis paragraph clause do not apply to any damage or lass caused solely bythe negligenec of the CITYOr PALMETTO or any of its ageuts or employees

1 HgVE READ AIvTD UNDERSTAND THE gI30VE SPECIgLFUVCTION PERIITAPLlCATiONCONDITIONS AND INDEMNITY

Permittee

CITY APPROVAL

fPublic Works Director

Date

Risk Management Date

Parks Liepartmcnt DatePolice Deparemcnt Datc

North Ffiver Piro Date

APPROVED BY COMMISSION Date

Inlctnal use onlyDate Received

NeRT4 PIVER FIRE IS 941 721 6701

Feb 07 68 84OBp City of Pal metLo

Special Fr21rCr1Urr FCYrtrrAplylication

Fage 2

EVENT PY41

020606 02 10pm P 006

8417234576 p3

EventAlutr n X 1J

INDEMNITY

4 ss0JCyYtP 1iStC or Pelminee agrees to defend indemnify and hold harttsiess deC1YOF

PALMETTO its officers agents employees and vaiunteers liom ail loss cost and expeil8e arisin ostGi ally

liability or claim or liability for petsarsai injury bodilyirjtuy to persons contractual liability anal damage to

property sustained at tlaimed to have been sustained azising out of activities of the Permittee or hose of any of

its officers agents employees licensees or invitees whether such act is authorized by this permit or not and

Pcmciucc shall pay Cor uty atld ail damage to the propcriy of theCTYOT PALMETTO or ionsorrjeft of such

properly done or caused by such persons CITY OF PALh9ETT0 aasturres no responsibility witatsaveror

any property placed on the premises Petmittee further agrees to waive all rights ofsubrogationaainst CITY

OF PALMETTO The provisions of this paragraph clause do notapply to any damage or loss caused solely by

the negligence of the CiiYOF FALMETTO or anyo its agents oz employees

I HAVE READ AND UNDERSTAND T1EABOVE SPECIAL FUNCTION PERMST APPLICATION

CONDITONS AND INDEMNITY

Permittee

CITY APPROVAL f

Public WorksDirectal

Risk Managcmcnt

ate

Date

Parks Deparhnent Date

Police DeparlmenDate

North Rivee Fire Y

Date

APPROtiEABY t MISSION Date

infemai use onlyDale Received

JAN182008 0316

ACORD CERTIFICATE OF LIABILITY INSURANCEvRODUCER PnorKn 9414223238 FEx gal7231E5 THt CERTIFICATE IS 199UED AS A MATTER

MOORE MOORE INSURANCE AGENCYHOLDER TH gNCERTIFiCATE DOES NOT AME

601 8TH AVE WEST ALTER THE COVERAGE AFFORDED BY THE P

PALMETTO FL 342215115 I

INSURERS AFFORDING COVERAGE

INSURED

PALMETTO HISTORICAL COMMISSION INC

PO80X1192PALMETTO PL 34220

pNY REQUIREMENT TERM OR CONDITION OF ANY COMRACT OR DTMEH wwmcn

MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED NEREIN IS

POLILIEb AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED SY PAID CLAIMS

NSR PDD TPOLICYNUMBERDDI

TYPE OF INSURANCE

X COMMERCIAL GENERAL LIABILITY

CLAIMS MADELI OCCUR

GENLAGGREGATE LIMITAPPLIES PER

PROLOCPOIICV JEGT

AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED AUTOS

SCHEDULED AUTOS

IIHIRED AUTOS

I NONOWNED AUT09

IGARAGE LIABILitt

ANY AUTO

EXCESS UMDRELLA LIABILITY

OCCUR ClAIM6 MADE

DEDUCTIBLE

RETENTION S

WORKERS COMPENSATON AND

EMPLOYERS LIABILI1Y

qNYPROPRETORrvAATNERiEECUTNEOFFICERIM6MBER EXCIVDED9

paUSLnIDe Yi1Cef

SPECIAL PROVISIONS Delaw

OTHER

DESCRIPTION OF OPERATIONSILOCATIONSNEHCERTIFICATE HOLDER IS ADDITIONAL ENSURED

ACTIVITY Heritage Day 09082008

CITY OF PALMETTOP 0 BOX 1209

PALMETTO FL 34221

Attention Peggy Martin

ACORD 25 2001OBCenlflDete

A GBneral Ins Co of Ameriea

C

D

NAIC

TD WHICH THIS CERTIFICATE MAY BE ISSUED OR I

THE TERMSECWSIONS AND CONDITIONS OF bUCH

DOLICYEPIRATIDN LRAIT6DATE MMDD

3 00000010210609 EACH OCCURRENCE

OAMR6E TO REMED DOQDDPREMISES ED OCCUranceMED EXP Y ene peraon S 10000

PERSONALBADV INJURY S 1000000

GENERAL AGGREGATE S 1000000

PRODUCrscoMF10PAGG s 1000000

COMBINED SINGLE LIMIT

Ea aaidenll

GODLY INJURY

Per person

BODILY INJURYIPcraaitlenf

AVTO ONLY EA ACCIDENT

OTHER THAN EA ACC

AUTO ONLY AGG

EACH OCCURRENCE

AGGREGATE

Poz JJDATE MMIDDIYYYY

olnsa9Da

INFORMATIONiTIFICATEEXTEND OR

ELEACH ACCIDENT

EL019EASEEAEMPLOYEE

ELDISEASEPOLICY LIMB

ADDED BY ENDORSEMENT SPECIAL PROVISIONS

SHOULD PNY OF THE ABOVE DESCRIBED POLICIES BE CANCEllEO 9EFORETHE

WRITTENONOT CTE TO 7HE CERTFICATENHOLOERRNAMEDLON THE OTOBVTIFAILUREYbTO DO SD SHALL IMPOSE NO OBLIOPTION OR IIAEILItt OF ANY KIND UPON THE INSURER

ITS AGENTS OR REPRESENTATNES

Jam MooreJr Ext 28

m ACORD CORPORATION 1988

4CCD CERZiFICQYE OF LIAILITfINUFiQNCE oPID T OATEMMICDhYYYJiveoaucER M2DT01 062307

eTHIS CERTIFCATE IS RSOED AS A HATTER OF INFORMATION18radenton IaaLranCe Inc

1ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATEU1iG0 Ballard park Drive Ptest

HC LDER THIS CERTIFICATE GOES NOT AMENG EXTEND OR

Bradentaa FL 342058719ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW

I Phoae 9417480511 Fax94174664441

INSURERSAFFORDING COVERAGE iNAICrLS FER Westfield Insurance Co p4112biidTown CateringMldTrnvn Cafe inc dba

RERE

t1902 th Strett WestPalmetta FL 342214312 I INS RFFD

Li tiQ IIIsCF F CJJ HAI LtiF I EDEC TOT4 KOREL tl CFCFORT RAREPO NCI AiCNn VTTII16M1M1 P JJ EI fl IEPV F1 N 1 N OF H C t P ICER CO LfNE Y N H3 FIiF FCRC1 VF wJL rIF E3R2EDN RER IS SL

HiCSFECi i4hl1 hTHSIETIF EVKr EE ISF EtOrcF

I

EL1G NbR p tlREUEIEt PAp Gp43

J TTO bf TE Vc YCLLKIQ NDfCCI r Ltl

w F5R YF CI N3 RANCE POLICY NLMEER

iETDTCRERPIi6Cti CT

DATE MMR10nI DATE MW IEM1lRALLAB LRD f LIMITS

I

A I Cf rShEcaaEai 0Qp 3 699 669rr jE t5YJJR 4A 3

PecfcnD06107i 0615061 OOO ODC

I abU LLaC 1 X A UPp2e1EEa oouxral YI 10000

I i j Ew ccv 10000i I I FrJ CI

I 1oeoooqI GE 10 RL PE I rS 6E E S D ODOtlGO

1Fx Ii i i i Fn PP F 2 000000j

L r rADa sIASamI

I J iO r pE l I ILIi

I nL5 tI ILEDUT

IC CINJLI iriCxrscr

jHkFCxT01IahipgclTCS I dINJLIFi

IIF d

1

IrII i iPPr ER L4wc4

T IFe x0

GARAELIABILITY

j oLrtJ VLFECCJEM1I

IL

C IECSSltMDRRLA Llgl TY

II CWREKfE 1f

L 4FE34TE R

j I iI i

bGtxi

I

VURIERS COMFENcAtION ANOr jEMPtJteR5LIABITY

i RrLlG1i11 EcI Fi F M 4TEP E ELIyE I E C4 ACIOE 5l ER FFREJLU i

Fs a a n E Ea EE 1LJt

2LLwwocicu j jv OTHEx CIxcE tt4JIi ij

I j

I II ESC

WYTCNCf CPERATro NSLOCATIONS FFliK LEf EYCLVSION9IuDeU8f ENDORSEMENT SPECUL PRORSION3iCERTIFICATC

HbtcRCity

of Palmetto POBox 1269 PalmettoPL 3422C 1209CITYP

3SHOULD ANY OF HE AB04E UESCRIEEO POLICIES EE CANCELED BEFORE THE EPRiTIONOATE

TNEP EOFTHEISSJNG MSURERMLLFUDEA40ftTMAIL10 LAYS 4JRtTTEn1 NO

CETOTHG CERT FICATEHOLDER NAMEDTOTIE LEFT BJFtiLLPtE TO00 50 SeALL IIAPOSE

NCOBLIGATIUNOR LNB UTOFANY K NOUPON THE INSURER ITS AGENTS OR

lfluLll7Lfi7 Page 1 55040 1187Issued 04132007

INSURANCE COMPANY TAILORED PROTECTION POLICY DECLARATIONS

6101 ANACAPRI BLVD LANSING MI 489173999

Renewal Effective 06092007neecv BOYD INSURANCE 8 INVESTMENT SV

12001000 MKT TERR 068 941 7220564 POLICY NUMBER 0623122068478907iNSUaeo MANATEE COUNTY AGRICULTURAL

MUSEUM INCCompany POLICY TERM

nooaess PO BOX 1284 Bill 1201 am 1201 am

PALMETTO FL 342201284 06092007tO06092008

In consideration o payment of the premium shown below this policy is renewed Pleasa attach thisDeclarations and attachments to your policy If you have any questions please consult with your agent

COMMERCIAL GENERAL LIABILITY COVERAGE

LIMITS OF INSURANCEGeneral Aggregate 2000000

Other Than ProductsCompleted OperationsProductsCompleted Operations Aggregate 2000000Personal Injury And Advertising Injury 1000000Each Occurrence 1000000

Commercial General Liability Plus Endorsement 55091

Damage to Premises Rented to You 300000 Any One PremisesFire Lightning Explosion And Water Damage

Medical Payments 10000 Any One PersonHired Auto 8 NonOwnedAuto 1000000 Each Occurrence

Expanded Coverage Details See FormExtended WatercraftPersonalInjury ProtectionBroadened Supplementary PaymentsBroadened Knowledge Of OccurrenceAdditional ProductsCompleted Operations Aggregate

Twice the General Aggregate Limit shown above is provided at no additionalcharge for each 12 month period in accordance with form 55300

AUDIT TYPE NonAudited

FORMS THAT APPLY TO LIABILITY 59350 CO106 55146 C0604 55091 C07OSIL0021 C1185 55296 07OS 55300 0705 CG0220 0792 IL0017 118555168 1204

LOCATION OF PREMISES YOU OWN RENT OR OCCUPY

LOC 001 BLDG 001 1015 6Th St W

Palmetto FL 342214601

TERRITORY 006

Classification

COUNTY Manatee

PremiumSuhline Basis

CODE 00501Commercial General Liability Plus PreenOpEndorsement Included At 7 Of ThePremises Operation Premium

PreenOp PreenInc

Rates Premium

Inc Inc

55040 1187

AUTOOWNERS INS CO Issued 04132

ns Ervcv BOYD INSURANCE 8 INVESTMENT SV Company POLICY NUMBER 06231220684789112001000 MKT TERR 068 Bill

insuaEO MANATEE COUNTY AGRICULTURAL Term 06092007 to 06092008

COMMERCIAL GENERAL LIABILITY COVERAGE

CODE 46427 Area Each 1000Museums PremOp 6000 201323 5120800Including Products AndOr CompletedOperationsNotFor Profit

CODE 49950Additional InterestsManagersLessors Of Premises PremOp 6000City Of Palmetto

FOREIGN TERRORISM CERTIFIED ACTS SEE FORM 59350

7770 54700

51300

LOCATION 001 PREMIUM 5126800

Code 12001000 Policy Number 06231220684789

COMMERCIAL GENERAL LIABILITY55188 1204

THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY

ADDITIONAL INSURED MANAGERS OR LESSORS OFPREMISES

This endorsement modifies insurance provided under the following

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

1 Designation of Premises Part Leased to You1015 6TH ST W PALMETTO FL 34221

2 Name of Person or Organization Additional InsuredCITY OF PALMETTD

3 Additional Premium

If no entry appears above information required to complete this endorsement will be shown in the Declarations as

applicable to this endorsement

A SECTION II WHO IS INSURED is amended to include as an additional insured the person or organization shown in the Schedule but only with respectto liability arising out of the ownership maintenanceor use of that part of the premises leased to you andshown in the Schedule and subject to the followingadditional exclusions

This insurance does not apply to

1 Any occurrence which takes place after youcease to be a tenant in that premises

2 Structural alterations new construction or demolition operations performed by or on behalf

of the person or organization shown in the

Schedule

B Under SECTION III LIMITS OF INSURANCE the

following is added

The limits of liability for the additional insured are

those specified in the written contract or agreementbetween the insured and the manager or lessor of

premises not to exceed the limits provided in this

policy These limits are inclusive of and not in addition to the limits of insurance shown in the Decla

rations

Includes copyrighted material of Insurance Services Office Inc with its permissionCopyright Insurance Services Office Inc 1984 2003 Page 1 of 1

wrtr

x


EVENT NAME fiC t EVENT DATE 1 C

APPLICANTCCtrn SoY iCc CSS iliti EVENT TIME 1 M 1UADDRESS 10 UQ 1s3 mO PHONE

CONTACT 1a5 py PHONE c 3 9

DETAILS OF FUNCTION LOCATION ERQUTE ETC cCQs QQOLSL Ses y 2 hut11CO K Ca Qr


If a temporary restroom is utilized for a period greater than five 5 days a Temporary Use Permit is requiredApplication is available at City Hall

TEMPORARY RESTROOM FACILITIES of units ofdaysProposed locations

INSURANCE REQUIREMENT Organized events open to the public require insurance naming the City ofPalmetto as an Additional Insured and the insurance policy must be provided to the City Clerk ten 10 daysprior to the event If you have entered into a rental agreement for a City facility for a private event noinsurance is required Please review Exhibit A for insurance coverage requirements

The Special Function Permit Application must be submitted to City Commission for approval at least 30 daysprior to the event Sale or consumption ofalcoholic beverages on City property is strictly prohibited If yourevent will include the use of loudspeakers you may be required to apply for a Special Permit Exception to theCitys Noise Ordinance See Chapter5Amusements of the City of Palmetto Code of Ordinances

TIIIS PORTION OF TAE PAGE INTENTIONALLY LEFT BLANK


NORTH RIVER FIRE DIS 941 721 6701

Feb 07 D8 0409p Cita of Palmetto

Special FuuctloePermit ApplicationPage 2

EVENT Cl llY

0210808 02 00pm P 003

9427234576 p5

Event Date 3121 G

TI1i18IMNTTY

Ggt41 l tILtC iCPetmittee agrees tc defend indemnify and hold harmless etta CITY OF

PALMETTO its offtcersagents employees arzd volunteers from all lots cost avd expense arisia3outofqtly

liability or claim or liability for personal injury bodsly mtury to persons covtractual liablity and damage to

Property sustained orclaimed to have been sustained arising out of activities of the Petmitfee or titcse ofany of

its officers agents etngloyees licensees or invitees waether such act is authorized by this Permit or not and

Perntitte 2vilt pxy fur arty mtd alldattuge xu the proPetty o thr CITY OF PALMETTO or loss ox hcA ofsuch

property done or caused by such persons CITY OF PALMETTO assumes no responsibility vfiatsoever for

DIY PIoPerty Alaced an the Premises Psrmittee ftutiher agrees to waive all rights of subrogation a3ainst CITY

OF PALMETTG The provisions ofthis paragraph clause dv nut appyto any damage or loss caused solely by

the aegiigence ofthe CITY OF PALMETTO ar any of its agents ar employees

I HAVE R1rAD AND UNAERSTAND TIIE ABOV SPIrCIAL FUNCTION PERMIT APILICATIOtt

CGNDTTIONS AND INDEMNITY

Penx2stteet

CITY APPROVAL


Risk Managnrcnt

Date

Date

Parks DepartmentDate

Police DepartmentDate

North Rivet FiraDate

APPROVED I3Y C SSION Date

Internal use an3yDateReceived

Feb OB 8 1153a Rntoinette Kilgore

Special Tuncteon YermieAaplicatlonPage 2

v Y

9411 7234930 p2

EvcntDatez i O

IieiDEMNITYelliSol1 sCYCCIPermittee agrees to defend indemnify and hold harmless the CITY OFPALMETTO its officers agents employees and volunteers from all loss cost and oxpense arising out of anyliability or claim or liability for personal injury bodily injury to persons contractual liability and damage to

property sustained or clainxed to have been sustained arising out of activities ofthe Permittee or those oIany ofits offcers agents employees licensees or invitees whether such act s authorized by this permit or not andPermittce shall pay for any and all damage to the property ofthe CITYOF PALMETTO or toss or then ofsuchproperty done or caused by such persons CITY OF PALMETTO assumes no responsihiliey whatsoever forany property placed on 4he prcrrlises Fertnittee further agrees to waive all rights ofsubrogation against CITYOF PALMETTO The provisions ofthis paragraph clause do not apply to any damage or loss caused solely bytheneiligence of the CITY OF PALMETTO or any ofits agents or employees

I HAVE READ AND UNDERSTAND THE ABOVE SPECIAL FUNCTION PERMIT APPIiCATIONCONDITIONS AND INDEMNITY

Peimttteex1 D 1

CITY APPROVAL

Public Works

Risk ManagementParks DepartmentPolice DepartmentNorth River Fire

APPRCVEDSY COMMISSION


Date

Date

Date

Date

Date

Date

JAN182008 0316 03jACORD

DATE MM1D0YYYY

TM CERTIFICATE OF LIABILITY INSURANCE i ovlalz6De

PRODUCER Phans 94t772B23B Fxa 9d1n3i785 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION

MOORS 8 MOORS INSURANCE AGENCY ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFlCATE

801 BTH AVE WEST HOLDER THIS CERTIFICATE DOES NO7 AMEND EXTEND OR

L 34221 51 1 5 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOWPALMETTO F

INSURERS AFFORDING COVERAGE NAIC a

Agerxy Lids Atate

INSURER A General lRS Co of America 24732INSURED

PALMETTO HISTORICAL COMMISSION INC INSURER e

P O BOX 1182 INSURER C

PALMETTO FL 34220 INSURER D

INSURER E

COVERAGESinrniuATeunlNr

THE POLICIES OF INSURANCE LISTED BELOW NAVE BEEN ISSUED TO mE msuneu ngmeu now rvn vim

Y CONTRACT OR OTHER DOCUMENT WRM RESPECT TO WHICH TRIG CERTIFICATE MAY BE ISSUED ORwNY REgUREMENi TERM OR CONDITION OF AN

V THE POLICIES DESCRIEED HEREIN IS SUBJECT i0 wLL THE TERMS ECWSIONS AND CONDITIONS OF SUCH

MAY PERTAIN THE INSURANCE AFFORDED B

POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED 8Y PAID CLAIMS

IMSR ADD TYPE OF INSURANCE POLICY NUMBERPOLICY EFFECiNE POUCY EMPIRpnon

DATE MMI GATE MM0MLIMITS

LTR INeR

GENERAL LwBILITY D10L3305631 020608 0270609 ECH OCCURRENCEnC

1000000E TO RENTED SMM 200006

X COMMERCIAL GENERAL LIABILITY PREMIeas EaDwum

CLAIMS MADE X OCCURMED ExP Anpone Person S 10000

IPERSONALADV INJURY S 1000OOD

ESGENERAL AGGREGATE S 1000000

GENLAGGREGATE LIMIT APPLIES PERPRODUCTSCOMPIOP AGG 1000LOOO

POLICYPRO

LOCJECT

AUT OMOBILE IMBILITY COMBINED SINGLE LIMITSEa aeotlenU

qNV AUTOBODILY INJURY

ALL OWNED AUTOS Perpcrsm

SCHEDULED AUTOS

HIRED AUT05 BODILY INJURY SPar ettltlern

NONOWNEDAUTOS

PROPERLY DAMAGE S

ACCIDEN7AUTO ONLYEl S

GPRAGE LIABILITY

OTHER THAN EA ACC SANV AUTO NLYAU70 O AGG

EACH OCCURRENCE S

EYCESS UMBRELLA LIABILITYAGGREGATE

OCCUR CLAIMS MADE

S

DEDUCTIBLE5

RETENTION S NC aTATNETHER

WORKERS COMPENSATION ANDTORY UMIiS

EMPLOYERS UABILIN ELEACH ACCIDENT S

pNYDRODwETDRPARTNEPIECUTIVE E LDISEASEEAEMPLOYEE SOFFICERRAEMBEREGWDED9

rcyeeearBDmMOr EL DISEASEPOLICY LIMIT S

sPECUL PRPV01ONa Eelow

OTHER

NENICIESIEXCLUSIONS ADDED 8Y ENDORSEMENTI SPECIAL PROVISIONSDESCRIPTION OF OPERATIONSILOCATIONSCERTIFICATE HOLDER IS ADDITIONAL INSURED

ACTIVITY Family Fun Day 0312112 008

CANCELLATIONERTIFICATE HOLDER

SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCEILEP BEFORE THE

EPiRA7E0N DATE tMEREOF THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS

N NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT BIIT FAILUREWRITTETO DO SO SHALL IMPOSE NO OBLIGATION OR 11A81LfiY OF ANY KIND UPON THE ENSURER

CITY OF PALMETTO ITS AGENTS OR REPRESENTATIVES

P O BOX 1209PALMETTO FL 34221 AUTHORIYED REPRESENTATIVE

Jam Moore Jr Ext 28Attention Peggy Manln

ACORD CORPORATION 1989

ACORD 26 200108 Certificals 13922

SPECIAL FUNCTIONPERMITAPPLICATION

EVENT NAMEr EVENT DATE d

APPLICANTaSr a r C fittirsSc EVENT TIME tl lyADDRESS 0 flak tt PHONE

CONTACT xctS 0 n PHONE a 3

OF FUNCTION

rCv C lC n R eh eCITY SERVICES REQUIRED yPOLICE Streets Blocked Traffic Control Security OtherPUBLIC WORKS Barricades Cleanup Setup Other



INSURANCE REQUIREMENT Organized events open to the public require insurance naming the City ofPalmetto as an Additional Insured and the insurance policy must be provided to the City Clerk ten10 daysprior to the event If you have entered into a rental agreement for a City facility for a private event noinsurance is required Please review Exhibit A for insurance coverage requirements


TINSPORTION OF THE PAGE INTENTIONALLY LEFT BLANK



Feb 07 08 0409p Ctta of Palmetto

Special Function Perwit ApplicationPage 2

02t06l06 0200pm P 005

9417234575 p7

Evcat Dats o

ixnEaixlTS

itSLO StuuutYemxiaee agrees to defend indemnify and hold harmless the CtTX OF

PALMETTO its oticers agents employees and volunteers from aIi Ions cast and expense arising out of any

liability ar claim ar liability far personal injury bodily injury to persons conVaetuaI Iiahiiiry anti damage to

property sustained ar claimed to have been sustained arising outof activities of thePerrnirtee ar these of any of

its officers agents employees licensees or invitees whether such act is authorized by this perntis or not atxl

Permittee shall pay for any and all damage to theproperty of the CITY OFPALMfT0or loss or heft of such

property done or caused by such persons CITY OF PAIMFTTO assumes no responsibility whatsoever for

any ptoperty pieced on the premises Permittee further agrees to waive atl rights of subrogation asinst CITY

OF PALMETTO the provisions of this paragraph clause da not apply to any damage or 3oss caused solely by

the negligence of the CITY OF PALMETTO or any ofits agents or employees

I HAVE READ AND UNDER3TPxDTI3E ABOVE SPECIAL FUNCTION PERMIT APPLICATION

CONDITIOIISARID INDEMNITY

Permlttee

CITXAPPROVAL

Public Works Direcior

Risk ManaKement

Parks DepartmentPolice DepartmentNorth River Fire

APPROVED BY ISSION

Interlal use osdyDate Received

Date

Datc

Date

Date

Date

Date

Feb 08 08 1153a Rntoinette Kilgore

Special Function Permit ApplicatiotsPage t

EVEIKTL o S Event r3ate O a

INDEl1VITXkl X11 t h5 v

ilia S 4 CcO1Pcrniittce agrees to defend indetnniPALMETTO ttsoiFicers agents employees and volunteers from a1 loss ostnand expenelarisi geaut ofanyLiability or claim or liability for personal injury bodily injury to persons contractual liability and damage toproperty sustained or claimed to have been sustained arising outofactivities of the PermiHee or hose ofany ofits officers agents employees licensees or invitees whether such act is authorized by this permit or not andPennittee shall pay for any attd all damage to the property ofthe CITY OF PALMETTO or loss or then ofsuchproperty done or caused by such persons CITY OF PALMETTO asstlrnes no responsibility whatsoever forany property placed on zlle premises Pemtittce fiirther agrees to waive all rights ofsubrogation against CITYOF PALMETTO The provisions of this paragraph clausedonot appty to any damage or foss caused solely bythe netigenec ofthe CITY OF PALMETTO or any ofits agents or employees

1 HAVE READ AND UNDERSTAND THE ABOV SPECIAT FUNCTION PERMIT APPLICATIONCONDITIONS AND INDEMNITY

U cPcrminec

CITY APPROVAL


Risk ManagementParks DepartmentPolice DepartmentNorth Fiver Firc

APPROVED BY COMMISSION

internal use orrlyDate Received

1941f 7234830 p3

Date

Date

Date

Date

Date

Date

JAN182008 0316 P 04 JDATE MNNDD1MY

ACORD CERTIFICATE OF LIABILITY INSURANCE 6111e12ooaTM

PRODUCER Phone 9417223238 Fax 9417237TB3 THIS CERTIFICATE 13 133UED A3 A MATTER OF INFORMATION

MOORS MOORS INSURANCE AGENCY ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE

601 8TH AVE WE5T HOLDER THIS CERTIFlCATE OOE3 NOT AMEND EXTEND OR

TTO PL 34221 5115 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOWPALME

INSURERS AFFORDING COVERAGE NAIC

A9eney LichtP183018mericaINSURER A General In4 CO Of A 24732

INSURED

PALMETTO HISTORICAL COMMISSION INC wSURER B

P O BOX 7792 INSURER CPALMETTO FL 34220

INSURER D

INSURER E

COVERAGESTHE POLI CIES OF INSURANCE LISTED BELOW H

N OFAVE BEEN ISSUED TO THE IN

NY CONTRACT OR OTHER DO

SURED NANItU AtlVVt r

CUMENT WITH RESPECTun Incrwe rc

TO WNICN THIS CE

nvo

RTIFICATE MAV BE ISSUED O RIANV REQ AUIREMENT TERM OR CONDRIO

RDED BY THE POLICIES DESCRIBED HER EIN IS 3U8JECT TO ALL THE TERMS ECL USIONS AND CONDITIONS OF 3VCH

MAYPOLI

PER

CIESTAIN THE INSURANCE AFFO

AGCd2EGATE LIMITS 3HOWN MAY HAVE BEEN REDUCED EY PAID CL AIMS

INBR ADDTYPE OF INSURANCE POLICY NUMBER DOLIGV EFFECTNE DOLICYBRATION

ATE MNDLIMR9

LTR MaDATE MMIDD

0000001GENERAL LNIBILITY 01OL9305637 6216608 020669 EACH OCCURRENCE

DAMAGE TO RENTED 266666X COMMERCIAL GENERAL LIABILITY DREnfisSLewNADI

URMED EXP Any one pwsDn 3 10060

CLAIMS MADE OCCPERSONAL B AOV INJURY ffi 1OOD666

GENERAL AGGREGATE 1000000

PRODUCTSCOMPOPAGG 11000006GEM L AGGREGATE LIMIT APPLIES PER

f I LOCPOLICY J IECT

AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT

E88a1DenUANY AUTO

6oDILY INJURYALL OWNED AUTOS per person S

SCHEDULED AUT09

HIRED AUTOSBODILY INJURY

WNED AUTOSPCraeeitleN

NONO

PROPEftNDAMAGEIPeYaulCan1

GARAGE LIABILITY AUTO ONLYEAACCIDENT B

ANY AUTOOTHER THAN EAACCAUTO ONLY AGG

EACH OCCURRENCE S

ECE99 UMBRELLA LIABILITY

OCCUR CWMSMADEAGGREGATE

S

DEDUCTIBLES

RETENTIONSI WC TATtI dfNERTORY LIMITS

WORKERS COMPENSATION ANDEMPLOYERS LIABILITY ELEACH ACCIDENT 6

ANY PRODRnFlORBARTNEWExEDDTNEOWDED9 ELDISEASEEAEMPLOYEE S

OFFICEIUM1fEMnER E

nlesnevennaunaor E L DISEASEPOLICY LIMIT

SPCCIPL DRONSIINJS ele

OTHER

LESIEXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONSDESCRIPTION OF OPERATIONSILOCATIONSNEHICCERTIFICATE HOLDER IS ADDITIONAL INSURED

ACTIVIT Gospel and Games Os1052068

CITY OF PALMETTOP O sOX 1209

PALMS7T0 FL 34221

Attendon Peggy Martin

SHOULD ANV OF THE ABOVE DESCRIBED POLICIE6 BE CANCELLED BEFORE THE

EPIRATION DATE THEREOF THE ISSUING INSURER WILL ENDEAVOR TO MAILID DAYS

WRfTTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT BUT FAILURE

TO OD 30 SHALL IMPOSE NO OBLIGATION OR LIABILITi OF ANY KIND UPON THE INSURER

fPS AGENTS Oft REPRESENTATNE6

Jarn MooreJrECORPORAYION 1988

ACORD 25 200108

ACORDN CERTIFICATE OF LIABILITY INSURANCE DATEMMODfNYY8142007

PRODUCER

DickJohnson Jefferson Inc PARRISH THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION

8405 US Hwy 301 NONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATEHOLDER THIS CERTIFICATE DOES NOT AMEND EXTEND OR

Suite 102 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOWParrish Florida 34219

INSURERS AFFORDING COVERAGE NAICINSURED

Clayton Allen INSURERA AIItDOWnerIDSUarteeLORI apP Y 1988

1411 9Th Avenue East INSURER B

Palmetto FL 34221 INBURER C

INSURER D

INSURER Ernueonree

THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDINGANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED ORMAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCHPOLICIES AGGREGATE LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMSINSR ODL

POLICY NUMBERPOLICY EFFECTIVE POLICY EXPIRATION

LIMITS

GENERALLIABILITY 20670825 712W7 71200 EACH OCCURRENCE 1000000A COMMERCIAL GENEFWLLIHBILITy DM1AG PEN

300 000PREMISES EaoccurenceCLAIMS MADE OCCUR

MEOEXP Any ona arson 10000PERSONALB 1 000 000ADV INJURY

GENERA G 1 000 000L A GREGATE

GENLAGGREGATE LIMITAPPLIES PER

PROPRODUCTSCOMPIOPAGG 1000000

POLICY LOC

AUT OMOBILE LIABILITY

ANYACOMBINED SINGLE LIMIT

UTO Ea eccitlenl

ALL OWNED AUTOS

SCBODILY INJURY

HEDULED AUTOS Perperson

HIREDAUTOS

NON OBODILY INJURY

WNED AUTOS Perawitlenp

PROPERTY DAMAGE

Per accitlenN

GARAGE LIABILITYAUTOONLYEAACCIDENT

ANYAUTOOTHERTHAN EAACC

AUTOONLYqGG

EXCESSlUMBRELLA LIABILITYEACH OCCURRENCE

OCCUR CLAIMS MADEAGGREGATE

DEDUCTIBLE

RETENTION

WORKERS COMPENSATION ANO oVC STATU GTHEMPLOYERS LIAe1LITYANYPROPRIETORPARTNEREXECUTIVE EL EACH ACCIDENTOFFICERMEMBERFXCLUDED4If yes describe under EL DISEASEEAEMPLOYEE

SPECIAL PROVISIONS below ELDISEASEPOLICY LIMITOTNER

DESCRIPTION OFOPERATIONS LOCATIONS I VEHICLES EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS

rcoronnrvu

HoldersNflhlre of Interest Certificate Holder

CityOf Palmetto

Pazks and Recreation516 8 Ave West

Palmetto FL 34221

SHOULD ANY OF THE ABOVE DESCRIDED POLICIES BE CANCELLED BEFORE THE EXPIRATION

CSI6 S DATE THEREOF THE ISSUING INSURER WILL ENDEAVOR TO MAIL I O DAYS WRITTENNDTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT SUT FAILURE TO 00 SO SHALL

IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR

ACORD


EVENT NAME Sy tl I am SGCi Q i Q r EVENT DATE

APPLICANTCrnnrYSllClCis1Stti EVENT TIME 11 R p M

ADDRESS J l O AgyQ CZ CLtZtO PHONE

CONTACT 1a G S C PHONE a g

DETAILS OF FUNCTION LOCATION PARADE ROUTE ETC

CITY SERVICES REQUIREDPOLICE Streets BlockedPUBLIC WORKS Barricades

Traffic Control

CleanupSecuritySetup

OtherOther


TEMPORARY RESTROOM FACILITIES of units of daysProposed locations

INSURANCE REQUIREMENT Organized events open to the public require insurance naming the City ofPalmetto as an Additional Insured and the insurance policy must be provided to the City Clerk ten 10 daysprior to the event If you have entered into a rental agreement for a City facility for a private event no

insurance is required Please review Exhibit A for insurance coverage requirements

The Special Function Permit Application must be submitted to City Commission for approval at least 30 daysprior to the event Sale or consumption of alcoholic beverages on City property is strictly prohibited If yourevent will include the use of loudspeakers you may be required to apply for a Special Permit Exception to theCitys Noise Ordinance See Chapter5Amusements ofthe City ofPalmetto Code of Ordinances

THISPORTION OF THE PAGE INTENTIONALLY LEFT BLANK



Feb 07 08 O4D9p City of Paloetto

SpetiaT FanCttnLtrntitAppiisxtiuPege 2

EVENT U nzhf t O C Y

02f08f08 0200pm P 007

941723456 pg

Event Datc C

IiDEMNITt

4 Chyyrss o

EKIjQO FlStUt tt1 Yermittee agrees to defend ittdemnify and hold harmless the CITY OF

PALMETTO its officers agents employees and volunteers iXOm ail toss cost and expense arlsllt cut ofany

Yirbiliry rctaint or liability for pelsonai injury bodily injury to persans contractual liability and damage to

property sustained or ciaimed to have been sustained azisntg out of activities ofthe Fetmittee or those ofany of

its offcers agents employees licensees ar invitees whether such act is autharized by his permit or not and

PCmitiCe Shaii pay for any and all damage ro the property ofilie CtCY OF PALMEtiartoss oz i3ecR of such

property done or caused by sach persons iIY 1P PALMETTO sssms nacapblixty whaiseverfor

anY property placed nn the premises Pemftteefurther agrees m waive aIrights ofsubrogatsnsmast CITY

OF PALMETTO The provisions of this paragraph clause do not apply to any damage or foss caused solely by

the negligenceofthe CITY OF PALMETTO or any of its agents or employees

I HAVl READ AND UNDERSTAND THE ABOVE SPECIAL FINCTION PERMIT APPLICATION

CONDITIONS AND INpEMNITY

Permittee

CITY APPROVAL

Public WorksDrQCtorDate

Lusk Rdanagemem r a4nf Date

YarksDepattment h6py Date

Police DepartmentDatc

North RfVC7 FireDate

APPROVED SY CO MISSION Date

Internai use onlyDate Received

Fep OB D8 1153a Antoinette Kilgore

Specia3kunction Permit AppcuriotlPage

EVEiTSviheC L R1 ll 1CG Y

19411 7234830 p4

Event bate 0

iND1VINiiTY

T QtTC1 S GcCal PSermStte agrees to defend Sndemnify and hold harmless the CITY OFPALMETTO Sts officers agents employees and volunteers from all loss cost and expense arising out ofanyliability or claim or liability for personal injury bodily injury to gersoms contractual tiabiliry and damage toprogeny sustained or claimed to have been sustained arising out of activities of the Permittee or those ofany ofits officers aficnts employees licensees or inviteos whether such act is authorized by this pemtit or not andPermittee shall pay for any and all damage to the property ofthe CITY OF PALMETTO or loss oz thc4 ofsuchproperty done or caused by such persons CITY OF PALMLTTO assumes no responsibility whatsoever forany property ptaced on the premises PcrmSttce further agrees to waive all rights ofsubrogation against CITYOF PALIti4ETT0 The provisions ofthis paragraph clause do not apply to any damage or loss caused solely bythe negligence of the CITY OF PALMETTO or arty ofits agents or cmplopees

I HA4E READ AND UNDERSTAND Tt3E ABOVE SPECIAL FUNCTION PERMIT APPLICATIONCONDITIONS AND 1NDEMNITY

Permittee

CITY APPROVAL

Public Works DirectorDate

RiskManagenaent tLr a Date

Parks Department DatePoliceIegartlnent DatcNorth River Fire

Date


Intemll use onlyDateFeceivccl

JAN162008 0316 1e2 P05

A CORDGATE MMODJYYYV

CERTIFICATE OF LIABILITY INSURANCE Dv132DDaTM

PRODUCER Pnone dotT223238 Fez 947T23ITBS THIS CERTIFICATE IS 183UED AS A MATTER OF INFORMATION

MOORE 8MOORE INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE

601 8TH AVE WEST HOLDER THIS CERTIFICATE DOES NOT AMEND EXTEND OR

LMETTO FL 342216116 ALTER THE COVERAGE AFFORDED BY THE POLICIES aELbwPA


ABenLiclk A1B907A

INSURER A General ins CO Of America 2a732INSURED

INCPALMETTO HISTORICAL COMMISSION INSURER B

P O BOX 1192 INSURER C

PALMETTO FL 34220INSURER D

INSURER E

COVERAGES nrnucTnunlNr

THE POLICIES OF INSURANCE LISTED BELOW H

ON OF AT

AVE BEEN ISSUED TO THE IN

NY CONTRACT OR OTHER DO

SURED nAMev APVVe r

CUMENT WRM RESPECTun Incru c

TO VVHICH THIS CERTIFICATE MAV BE ISSUED O R

ANY IREQUIREMENT TERM OR CONDIED BY THE POLICIES DESCRIBED HER EIN IS SUBJECT TO ALL THE TERMS EXCL VBIONB AND CONDRIONS OF SUCH

MAY PERTAIN THE INSURANCE AFFORD

POLI CIE6 AGGREGATE LIMITS SHOWN MAY HAV E BEEN REDUCED BY PAID CLAIMS

INSR

LTR IADDT TYPEOPINURANCENRGG

POLICY NUMBERPOLICY EFFECTNE

DATE 0

POLICYEPIRAnONTEMMN

LIMI79

GENERAL LIABILITY 01OL3309837 021O6J06 0210IOB EACH OCCURRENCE 110001000DAMADE TOREeDEO

200000X COMMERCIAL GENERAL LIABILITY PREMIEEe ELI accuwmce

CLAIMS MADE OCCURMEDEP Any Dne person S 10D00

ESPERSONAL SADV INJURY 1000000GENERAL AGGREGATE S 1000ODO

GEM L AGGREGATE LIMIT APPLIES PER PRODUCTSCOMPIOPAGG S 1000000PRO

LOC1 POLICY JECT

AUTOMOBILE LIABILITY COMBINED SINGLE LIMITS

ANY AUTOEB ecCidenU

ALL OWNED PUTOBODILY INJURY

Per pPfeon

SCHEDULED AUTOS

HIRED AUT09 BODILY INJURYPer eccldenU

NONOWNED AUTOS

PROPERTY DAMAGE

Per accident

GAR AGE LIA9ILITY AUTO ONLYEAACCIOENT

ANY AUTOGTHER THAN EA ACC S

AUTO ONLY AGG 5

EACH OCCURRENCEECESSI UMBRELLA LIAEILTIY

OCCUR CLAIMS MADEAGGREGATE

DEDUCTIBLES

RETENTIONWG STA7V OTHER

WORKERS COMPENSATION ANDTORY LIMne

EMPLOYERSLIABIDTY E1EADH ACCIOENi

ANY PROPRIETDRmARTwNEXECtmveOPFlCERRdEMBER EXCLUDED9

ELDISEASEEAEMPLOYEE

ayesAeuaeeunder ELDISEASEPOLICY WMR S

SPECIAL PRDVISION9 Lclaw

OTHERSNEHICLESEXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS

bESCRIPTION OF OPERATIONSILOCATION

CERTIFICATE HOLDER IS ADDITIONAL INSURED

ACTIVITY Summnr Social and Book Fair 061282008

IPWA1niLvc

SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLED B

THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYSN DATE THEREOFTIOEXPIRA

WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT BUT FAILURE

TO DO SO SHALL IMPO6E NO OBLIGATION OR LwBILITY OF ANY KIND UPON THE INSURER

CITY OF PALMETTO ITS AGENTS OR REPRESENTATNES

pO BOX 1208

PALMETTO FL 34221 AULHDRIZED REPRESENTATNE

Atlention Peggy Martn I JamelsEMoore Jr Ext 28

CmHIMsletl 73924 ACORD CORPORATION1988


EVENT NAME U r3l j C lAPPLICANT YQc 1T6 SOr C C p SS

ADDRESS J S I RUB CimO

CONTACT Cyt 1 Sa w

EVENT DATE

rEVENT TIME I I tlM tw

PHONE

PHONE 3 q j


TEMPORARY RESTROOM FACILITIES of units of daysProposed locations



THIS PORTION OF TAE PAGE INTENTIONALLY LEFT BLANK



TIORTti RIVER FIRE DIS 941 721 8701

Feb 07 00 04 IOp City of Palmeteo

Special Function trrniiApplicationPage 2

EVLTiT Svttme SOr

0210808 0200pm P

9417234576

008

pll

RventDatsL

tiv7DEMPiIT1

ytiMiYtuSistiC 1ermSttee agrees iodefend indetnnkfy aald hvtct zartztlwss the CITE 6F

PALIvITTO its officers agents employees and volunteers Trom ail ions cost and expense atksily ant of any

liability or claim or habiiity for personal injttry bodily injury to persons conhactuai iabiiity atlc damage to

property sustained or claimed to have been sustained artsirg antas activities ofthe Permittee or these ofany of

its Offzcers agents employees licensees or invitees whetitec such act is authorized by this permit ar not ahd

Peamiaee shall pay for any and nil duuage to fire ptooaty of dtc CPTY OFPSMLTQor ions arthclt of such

property done or caused by such persons CITY F PATMEIIOasstunes no responsibility wktatsocver Tor

any property placed on the prettiises Permiteeftlrtiter agrees to waive afl rights of subrogation alainst CITY

OF PALMETTO The provisions of this paragraph clause do not apply to any damage or loss caused soteIy bythe negPlgence ofthe CITYOF PALMbTTt or any ofits agents oremployees

I ITpVH RLAD AND UNDERSTAND TIIF ABQVE SPECIAL FUNCTION PRh4tfAPILIGATION

CONDITIONS AND 1RTDEMNITY

Permittee

CITY APPRQVAL

Public Works DirectoY Date

Risk Mattageumutfencin cra r Date

Parks Department rt Date

Poiica t3epanmtmt Datc

North River Fire Date

APPROVED YC MISSION Date

Irttemal use onlyDate Received

Feb 08 08 1153a Pntai nette Kilgore

Special Function Permit ApplicationPage S

EVETfT SUIrneY SnC Cj

f9411 7234830 p5

Event pate Q 2 Q

INDEMNITYsSpa

y l i t n tvrni s 4YSn4Ccz1 Permittee agrees to defend indemnify and hold harmless the CITY OFPALMETTO its oflieers agents employees and volunteers from all loss cost atld expense arising outofanyLiability or claim or liability for personal injury bodily injury to persons contractual liability and damage toproperty sustained or claimed to have been sustained arising cut of activities of the Permittee or those ofany ofits officers agents employees licensees or invitees whether such act is authorized by this permit or not andPermittee shall pay for any and all damage to the property ofthe CITY OF PALMETTO or Loss or theft ofsuchpropertyydone or caused by such persons CITY OF PALMETTO assumes no responsibility whaisaevcr forany property placed oa the gzemises Permittee further agrees to waive all rights of subrogation against CITYOP PALMETTO The provisions ofihis pazagraph clause do noY apply to any damage or loss caused solely bythe negligence ofthe CITY OP PALMETTO or any ofits agents or employees

IIIAVb READ AND UNDERSTAND THE A3OVE SPECIAL FUNCTION PERMIT APPLICATIONCONDITIONS AND INDEMNITY

C cPermittee

CITY APPROVAL

PublicWorksDirecto G

I DateJ

Risk Managementwa r Date

Parks DepartmentDate

Police I3epaztment Date

North River PireDate

APPROVED BY COMMISSIONDate


JAN182008 0317 aP06DAT h

ACORD CERTIFICATE OF LIABILITY INSURANCE 011182008TM

PRODUCER Pnane 5017223238 Fsx Sat7211755 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION

MOORS MOORS INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THB CERTIFICATE

WEST601 8TH AVE HOLDER 8113 CERTIFICATE DOES NOT AMEND ExTEND OR

5115 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOWPALMETTO FL 34221


ASeney Lidi A 1e3DiINSURER A General Ins Co of America 24732

INSUREDINCICAL COMMISSION INSURER 0PALMETTO HISTOR

P O BOX 1192 INSURER CPALMETTO FL 34220

INSURER D

INSURER E

COVERAGES

THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUHEU Nnme nOwO rvn Inc

TKER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED ORR O

ANY REOUIREMENi TERM OR CONDITION OF ANY CONTRACT O

THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AllTHE TERMSECIUSION AND CONDITIONS OF SUCH

MAY PERTAIN

POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS

WeRAO1 TYPE OFINSURANCE POLICY NUMBER POLIOYQPFEeTNEMTE MMIDO

PoucYErviRATION LIMITSO Y MMIOO

LTR INuP0

GENERAL LIABILITY 010L3305831 02I06OE 02OSO9 EACH DCCURRENCE s 1000000AIMGETO RENTE 2DDIDDD

X COMMERCIAL GENERAL LIABILITY P1EMISEa IEa amurc

CLAIMSMADECXOCCURMED EXP Airy one pelsOn 10000

PEft30NALB ADV INJURY S 1000000ES

GENERAL AGGREGATE S 1000000

GENL AGGREGATE LIMB APPLIES PER PRODUCTSCOMPOPAGG S 1000000

PROLOCPOLICY JECT

AUT OMOBILE LIABILITY COMBINED 61NGlE LIMITSEa acciGenO

ANY AUTO

BODILY INJURYALL OWNED AU70S Pat parson S

DULED AUTOSSCHE

HIRED AU70S BODILY INJURY SPer eOClObnl

NONOWNEOAVTOS

PROPERTY DAMAGEverecpi4ern

AUTO ONLYEAACCIDENT3

GARAGE LIABILITY

OTHER THAN EA AGC S

ANY AUTO YAUTO ONL AGG 3

EACH OCCURRENCE 8

ExCEBS UMBRELLA LIABILITYAGGREGATE

OCCUR L CLAIMS MADE

8

DEDUCTIBLE

9

RETEN710N Sw0 sTAny OTHERTORY LiMli

WORKERS COMPENSATION AND

EMPLOYERSLIA8ILITY EL EACH ACCIDENT S

ANV PROPRIETORDARTNEWEEENTNE EL DISEASEEAEMPIOYEB S

OWICEWMBMBER EMCWEDP

DISEASEPOLICY LIMITE L 8nuTeeeFriNunaeraPECiALPRVIBIONS Eelw

OTHER

DESCRIPTION OFOPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS

CERTIFICATE HOLDER IS ADDRIONAL INSURED

ACTIVITY Summer Social 0810212 008

CITY OF PALMETTOP osox 1 zo9PALMETTO FL 34221

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES eE CANCELLED BEFORE THE

EXPIPATION DATE THEREOF THE ISSUING INSURER WnIENDEAVOR TO MAIL tG DAYS

WRITTEN NOTICE TO THE CERTIFICATE MOLDER NAMED TO THE LEFT BUT FAILURE

TOW 30 SNAIL IMPOSE NO OBLIGATION OR LIABILITY OF ANYKING UPON THE INSURER

ITS AGENTS OR REPRESENTATIVES

AttenLlon Peggy MartinJames Moore Jr Ext 28

pCORD 25 200108 Certificate 13925 ACORD CORPORATION 1988


EVENT NAME

APPLICANTrne 1 5ce SSC7rvADDRESS i 1 d PrCONTACTpc S GN

OF FUNCTION PARADE

EVENT DATE t O 0 D

EVENTTIME9m pPHONE

PHONE c t q


If a temporary restroom is utilized for a period greater than five S days a Temporary Use Permit is requiredApplication is available at City Hall


INSURANCE REQUIREMENT Organized events open to the public require insurance naming the City ofPalmetto as an Additional Insured and the insurance policy must be provided to the City Clerk ten 10 daysprior to the event If you have entered into a rental agreement for a City facility for a private event no

insurance is required Please review Exhibit A for insurance coverage requirements

The Special Function Permit Application must be submitted to City Commission for approval at least 30 daysprior to the event Sale or consumption of alcoholic beverages on City property is strictly prohibited If yourevent will include the use of loudspeakers you may be required to apply for a Special Permit Exception to theCitysNoise Ordinance See Chapter5Amusements of the City of Palmetto Code ofOrdinances

THIS PORTION OF THE PAGE INTENTIONALLY LEFT BLANK


NORTH RIVER FIRE DI6 941 721 6701

Feb tT7 D8 D4 t0p City of P3IfiLLO

SpaciatFuncxioo Permit eipplication

Pago 2

EVENT itt1 nvQ

020609 0200pm P 011

84k7234S7ti p 13

Event bate 1 0 I o

IPIDBMNITY

sC 5i6C dui Permitiee agrees to drkcnd iudeumity and hall harmless the CI1Y OF

PALMETTO its officers agents employees and volunteers fmm ail loss cost and expense arising ovt ofany

liability or claim ar iability or personal iglttry bodily injury to persons contractual IiabiiIty ant damage to

property sustained or claimed to have been sustained arising out of activities of the Permitteeor hose ofany bf

IIS OCCCSaent5 CnlptOyeeS licensees or invitees whether such aci is authorized by this permit or not and

Prnlliltce shall pay for any and all damage t0 the property o4 theCITY OFPAIMFlTar ioss orrlseft ofsuch

property done or caused by such persons CITY OF PALMETTO assumes no responsibility whatsoever for

aziy property placed nn the premises Perrllittee further agrees to waive all rights of subrogation aiainst CITY

OF PALMETTO A he provisions of this paragraph clause do not apply to any damage or lass caused solely by

the negligence ofthe CITY OF PALMETTO or anyoits agents ar employees

I HAVE REAR AND UNDERSTAND THE AHUVE SPNCIAL FUNCTION PERMIT APPLICATIdNCONDITIONS AND1NUMNCIY

rPermirtee

CITY APPROVRL

Publie Works Direct Date

Risk Managcmart f1PsaSwo Ietcs

Parks Departrstenttk8tj Data

Police Department p

Date

North River Fire Date

APPROVED YC MISSIOIDate

Internal use ordyDate Received

Feb 09 09 12 07p Rntoinette Kilgore

Speceal Funetion Permit ApplicariarlPage 2

J

9411 7234930 pl

Event YDate 1 a d

INDEMNITYtt CCCmS5 cnQtlQlG S QI tCC34 Pmtittec agrees to defend indemnify and hold harmless the CITY OFPALMLTTO Its oflicers agents employees and volunteers from all Ions cost and expense arising out ofanyIiability or claim or tiabiity far personal injury bodily injury to persons contractual liability and damage toproperty sustained or claimed to have been sustained azising out ofactivities ofthe Permittee or these ofany ofits offcers agents employees tieensces or invitees whether such act is authorized by this permit or not andPcrnlittce shall pay far any and all damage to the property oithe CITY OP PALMETTO or loss or theft ofsuchproperty done or caused by such persons CITY OF PALMETTO assumes no responsibility whatsoever forany property placed on the preanises Pemlittee fiuther agecs to waive all rights of subrogation against CITYOFPPLMLTTO The provisions of this paragraph clause do net apply to any damage or loss caused solely bythenelligence of the CITY OF PALMETTO or any of its agents or emptayees

I DAVE READ AND UNDERSTAND TIDE AI30VE SPECIAL FUNCTION PERMIT APPLICATIONCONDITIONS AND INDEMNITY

Penniree

CITY r1PPROVAL

Public Works DirectoDate

Risk Management andnk urjrrc Date

Parks Department F DatePaliee Department

DateNorth Diver Fire

DateAPPROVED i3Y COMMISSION

Date


JANSB2008 0317 P07

ACORD CERTIFICATE OF LIABILITY INSURANCEDATE MMDOMYYV

olrlar2ooaTM

PRODUCER Phone 9417223238Fex 941723178 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA TION

MOORS 8 MOORS INSURANCE AGENCY ONLY AND CONFERS NO RIGFfT3 UPON THE CERTIFICATE

601 8TH AVE WEST MOLDER TNIS CERTIFICATE DOES NOi AMEND EXTEND OR

PALMETTO FL 942215115 ALTER THE covERAGE AFFORDED BY THE POLICIES BELOW


Agency Lla7 A183078

INSURED mericaINSURER A GaneTal Ins Co of A 2d732

PALMETTO HISTORICAL COMMISSION INC INSURER a

P O BO 1192 INSURER CPALMETTO FL 34220

INSURER D

INSURER E

COVERAGES

THE POLICIE6 OF INSURANCE LISTED BELOW HAVE DEEM IS6UED TO THE INSURED NAMED ABOVE POR THE POLIGT PEKIVU IrvurorM CU w vv

TERM aft CONDITION OF ANY CONTRACT OR OTMEP DOCUMENT WITH RESPECT TO WHICH TMIS CERTIFICATE MAY BE ISSUED ORANY REQUIREMENTMAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS ANO CONDDIONS OF 9VLH

POLICIES A66REGA7E LIMITS SNOWN NUY HAVE BEEN REDVCED BY PAID CLAIMS

INSR 4DDL TYPE OFINSURANCE POLICY NUMBERlTR INSRD

POLICY EFFECTNE Poucr ExP11UTKl LIMBSOAIE MMIDD GATE MMIDOIYY

GENERAL LIABILITY Ot0L9305631 0210008 020609 EACH OCCVRRENCE 1000000pAMAGE TO RENrED 200 000

X COMMERCIAL GENERAL LIABILITY PREMIBEE EdOddYrofl40

ClA1MS MAOECOCCUR MEDEJP Any one pBrsonl 10000

ESPER60NALADV INJVRY 1000000GENERAL AGGREGATE 7000000

OENLPGGREGATE LIMIT APPLIES PERT PRODVCTBLOMPIOP AGG S 1000000PRO

POLICY JECT LOLAUT OM001LE LIABILITY COMBINED SINGLE UMR

ANV AUTOEa acGidaM1

ALL OWNED AUTOSBODILY INJVRY

Par parson

SCHEDULED AUTOS

HIflED AUTOS BODILY INJURY

ParamideMNONOWNED AUTOS

PROPERTY DAMAGEPFr aceidenl

GARAGE LIABILffY AUTO ONLYEAACCIDENT

NY AUTO OTHER THAN EA ALLS

pAUTO ONLY

AGG

FALH OCCURRENCE S

ECE33VMBRELLA LIABILITY

I CLAIMS MADEOCCUR AGGREGATES

DEDUCTIBLE

RETENTIONy4C STATLL OINeR

TION ANDBTORY LPdITa

AWORKERS COMPEN

EMPLOYERS LIABILITY ELEACH ACCIDENT 9

ANY PROPRIEioRIPARTNERlBECUTAIE DISEASEEA EMIPlOYEEE I S

OFFICERRAEM9E0 EMCLIIOED9

RyeaadaalPdvaer EL 016EASEPOLICV LIMIT SSPECIAL PROVm10N8 Cclow

OTHER

DESCRIPTION OFOPER4TIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT SPECEAL PROVISIONS

CERTIFICATE MOLDER IS ADDITIONAL INSURED

ACTIVITY Yartl Sale 100412008

CANCELLATIONCERTIFICATE HOLDER

SHOULD ANY OF THE ABOVE DESCRIBED POIICIE6 BE CANCELLED BEFORE THFSOORINO LUREIEFT BUT FAINANIEO TO THENOLDERNO7ICE TO THE CERT FICATEVRITIEN

TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KING UPON THE IN6URER

CITY OF PALMETTO ITS AGENTS OR REPRESENTATIVES

P O BOX 1208PALMETTO FL 34221 q iNORIZED REPRESENTATIVE

2a

pryyl7jtJ Er xJam Moore

Attention Peggy Martin

ACORD 25 20D1l08 CenlEiLae 13926 9ACOMU cor4rvNA41 lun 1700


EVENT NAMELipZPa1QCAPPLICANTQQn1tS rCcCtCsSSiVADDRESS I Rine QreCONTACT CcCc S

EVENT DATE Iq

EVENT TIME M Pte

PHONE

PHONE 1 y g J

If a temporary restroom is utilized for a period greater than five 5 days a Temporary Use Permit is requiredApplication is available at City Ha11

TEMPORARY RESTROOM FACILITIES ofunits of daysProposed locations



TffiS PORTION OF THE PAGE INTENTIONALLY LEFT BLANK



Feb 08 06 i153a Antoinette Kilgore 9411 7z34830 p6

Special Function Permit ApplicationPage X

EVENT YClii1121 jLC e Eveat Datc I G f4 r CS

t sia INDEMNITY

pniy ittCGI Pennittce agrees to defend indemnify and hold hamrless the CITY OFPALMETTO its officers agents employees and volunteers from all loss cost and expense arising out ofanyliability or claim or liability for personal injtry bodily injury to persons contractual liability and damage toproperty sustained or claimed to have been sustained arising out ofactivities of the Pcrmittee or those ofany ofits officers agents employees laaensees or inviees w1teLTter such act is authorized by this permit or nor andPermittee shall pay for any and all damage to the property ofthe CITY OF PALMETTO or loss or theft ofsuchproperty done or eauscd y such persons CITY OF PALMETTO assumes no responsibility whatsoever forany property piaced on the premises Permittee further agrees to waive all rights ofsubrogation against CITYOF PALMETTO Tltc provisions ofthis pazagraph clause do nat apply to any damage or loss caused solely bytheneligence of the CITY OF PALtifETTO or any ofitc agents or employees

I HAVE READ AND UNDERSTAND TIIE ABOVE SPECIAL FUNCTION PERMIT APPLICATIONCONDITIONS AND INDEMNITY

Permiitee

CITYAPPROVAL

Pubtie Works Date

Risk Ivlanagement Date

Parks Department Date

Police Department DateNorth 1Tiver Fire Date


Intenial use onlyDate Received

NORTH RIVER FIRE IS S41 721 6701

Feb 07 08 04 11p City o Palmetto

Special Functioa Perwii elppiicaiionFage 2

0208@8 0200pm P 013

went Dnce f

Bt3TEMPIITY

4

t1

thiCTO iSCiCEI EPesmitteo agrees to defend indemnity and hold hacmicss the CIZY Of

PALMETTO its officers agents employees and volunteers tom all loss cost and expense arising out of any

ixhility nr claim or liability for personal itury bodily iniury Eo persons contractual liability and damage to

ptopexry sustainedor claimed to have been sustained arising out of activities ofthe Petmitxee or those of any of

its officers agents employees tisensees or invitees whesher such act is authorized by this permit or not and

Yerrttittee shalt pay for any and ail damage to the pnlpexrty of the CITY OP PALMLTfO or loss or theft of such

properly done o caused by such pexsan CITY OF PALNtETTO assumes no responsibility wtratsoever for

any property placed on the premises Permittee flutitet agrees to waive all rights of subrogation against CITY

OFPAIMTO The psovtsiotts ofthis paragragh clause de trot apply to any damage or loss ceased solely by

the negligence of theCITY OF PALMETTO ns any of its agents oc employees

1 HAVE READ AND UNDIRSTPuID THE Fr4QU SlECIAL FUNCTION PERyIIT APiLICATION

CONDl1IONS AND INDEMNITY

1V5Permittee

CITY APPROVAL 1

Public Works Diretlos Date

Risk Management r rt40 r Date

Parks Department Date

Police DegarhnentDate

NotthRiverFire Date

APPROVED BX C IMISfiION Date

Internal use arlyDateReceived

JAN182008 0317 d Poe

ACORD CERTIFICATE OF LIABILITY INSURANCE DAT0718I2007TM

PRODUCER Phone 99TT223238Fgx 891T231785 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION

MOORE 8 MOORE INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE

601 8TH AVE WEST HOLDER THIS CERTIFICATE DOES NOT AMEND ETEND OR

PALMETTO FL 342215115 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW


Agency LIUi A1B3016

INSURED INSURER A General Ins Co OfAmrlca 24732

PALMETTO HISTORICAL COMMISSION INC INSURER B

P O BOX 1192

PALMETTO FL 36220INSURER G

INSURER D

IINURER E

COVERAGES

7HE POLICIES OF MSURANCE LISTED BELOW HAVE BEEN IS6UED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING

ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCVMENT WITH RESPECT TOWHICH THIS CERTIFICATE AMY BE ISSUED ORMAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN Ib SUBJECT TO ALI THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH

POLICIES AGGREGATE LIMITS SHOWN MAY NAVE BEEN REDUCED BY PAID CLAIMS

INSR ADDL TYPE OFIN9URANCE POLICY NVMBERPDDEV EFFECTIVE PaIICY EXPIRADON LIMBS

COMMERCIAL GENERAL LIABILITY

CLAIMS MADE X OCCDR

i eixcnx7

irry arre peraen S

S ADV INJURY S

GGREGATE 6

1

GENLAGGREGATE LIMBAPPLIES PER PRODUCTSCOMPIOPAGG S 1000rDOOPRO

POLICY JECT LOC

AUT OMOBILE LIABILITY COMBINED SINGLE LIMBS

Ee eccidan0ANY AUTO

ALL OWNED AUTOSBODILY INJURY

PerPerFDnlSCHEDULED AUT03

HIREDAUTOS BODILY INJVRYPeracclCEM

NONOWNED AUTOS

PROPERTY DAMAGE SIPeremlaern

GARAGE LIABILriY AUTO ONLYEAACCIDENT S

ANY AUTO OTHER TKAN FA ACC 6

AUTO ONLY pGG 6

EACH OCCURRENCEEXCESSUMBRELLA LIABILITY

OCCUR CLAIMS MADE AGGREGATE

S

a

DEDUCTIBLE

RETEN710NWCBTATU OTHER

TW N AND6 roaY uMiTEAWORKERS COMPENEMPLOYERS LULBILRY EL EACH ACCIDENT 5

ANY PROPRIETORIPARTNEPIeXEC11TME DISEASEEAEMPLOYEEE L 8OFFlCERIMEMIER E1EWDED9

nvez 9eselme unear ELDISEASEPOLICY LIMIT 6

DESCRIPTION OF OPERATIONSILOCATIONSrvema

CERTIFICATE HOLDER IS ADDRIONAL INSURED

ACTIVITY Halloween Social 10l24f2008

BY ENDORSEMENTI SPECIAL PROVISIONS

CERTIFICATE HOLDERSHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE

THE 16SUING INSURER WILL ENDEAVOR TO h1AIL 10 DAYSEPIRATION DATE THEREOF

WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT BUT FAILURE

TO DO SOSHALL IMPOSE NO OBLIGATION Oft LIABILITY OF ANY KIND UPON THE INSURERCITY OF PALMETTO

ITS AGENiS OR REPRESENTATNESP O BOX 1209PALMETTO Fl 36221 AUTMORI2ED REPRESEMATNE

Attention Peggy Marlin Jam Moore Jr Ext 28

Ml AlfRflfYIRPIIRGTION 1f1aB

ACORD 25 200108

TOTAL POB

tab 3 - palmettodocsonline.palmettofl.org/.../city/2008/021808/commission/tab03.pdf · tab 3....

Documents