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Home My WebLink AboutProcession - Stanley Clark School1316 COUNTY -CITY BUILDING 227 W. JEFFERSON BOULEVARD SOUTH BEND. INDIANA 46601-1830 CITY OF SOUTH BEND PETE BUTTIGIEG, MAYOR BOARD OF PUBLIC WORKS September 13, 2016 Mr. David Story Stanley Clark School 3123 Miami St. South Bend, IN 46614 RE: Event: Clark Run for Enrichment Date: October 22, 2016 Dear Mr. Story: PHONE 574/235-9251 FAX 574/235-9171 The Board of Public Works, at its meeting held on September 13, 2016, approved your request to conduct the above referenced event on October 22, 2016 from 8:30 a.m. to 11:00 a.m. Enclosed please find copy of your approved permit. The South Bend Police and Traffic and Lighting Departments will supply traffic control. Please call this office at (574) 235-9251 with further questions regarding this matter. Sincerely, Linda M. Martin, Clerk Enclosure c: Gene Eyster, Police Department Federico Rodriguez, Fire Department Marcia Qualls, Streets Paula Gans, Parks Department GARY A. GILOT DAVID P. RELOS ELIZABETH A. MARADIK JAMES A. MUELLER THERESE J. DORAU INTER -OFFICE MEMORANDUM BOARD OF PUBLIC WORKS DATE SENT: 7/12/2016 TO:d Gleckler, Traffic &Lighting ederico Rodriguez, Fire Department J9corbitt Kerr, Engineering /Paula Garis, Park Department J Lt. Gene Eyster, Police Department Adam Burck, Downtown South Bend (aburck@downtownsouthbend.com) •JMarcia Qualls, Engineering Legal Department FROM: Linda M. Martin, Clerk_`) SUBJECT: PROCESSION RECOMMENDATION SPONSOR: Stanley Clark School DATE OF EVENT: October 22, 2016 DATE DUE: July 19, 2016 FAX OR E-MAIL TO: 235-9171 / Imartin(ftouthbendin.gov RECOMMENDATIONS AND COMMENTS: By Date From: Thomas Story Fax: (866) 610-8379 To: +15742359171 Fax +15742359171 Page 2 of 3 07106@016 8:52 AM APPLICATION FOR USE OF u � u PUBLIC It1GHT" WAV FOR PROCESSIONS The Board of Public works must have FOUR (4) weeks prior notice of the event." iWl Sponsor. Geri % ck e-x J Address: 7'1,<';t3 %1 rct, r:` SA City: '�d%.A State: _ Zip.GLly Submitted By: 1 + Ste r� Phone. &';Zq� , i /. — to '—' Sponsor may use the public fight -of -way described as (describe route and attach map) PLEASE NOTE:' iE.SO lTH BEND POi10E DEPARTMENT RESERVES THE RIGHT TO CHANCE YOUR ROUTE FOR SAFETY' PURPOSES Event name: ('� (,� K-f.l Y� i�� EYl � I CV1V1i]t°r1�-- The Board'of'Public works must have F0VR (4) weeks priornotice before event occurs All certificates, of insurance, pre paid costs, maps, and any other applicable information. requested or required by the Board of'Public works have been provided with this application 0 The evem shal I be held on 2L± 91A ^d, 20 14 and no ohar date 0 Registration time for the event starts at BYO 10 Jp.m. Starting time of the precession is a mJp.m. C] Estimated completion Gtne is,lp.m. This event involves the use ofthefollowing roadways This event involves City streets d This event involves County.roads Q This event involves State highways This event involves use of a park (Must obtain permission from Park Board) 1 understand that:1, must arrange a meeting with all affected governmental agencies to organize the above event (Calf Marcia Qualls, Customer Service Manager, 235-5939 to organize meeting) This event involves the use of the sidewalk Ef Participants, must stay on the sidewalk and obey all tral%e laws. This event is < egional/national event' (Please circle the appropriate event type) This event will be coordinated with the property owner/business where staging will take place Updated 4/06116 From: Thomas Story Fax: (866) 610-8379 To: +15742359171 Fax: +15742369171 Page 3 of 3 07l0672016 9:62 AM PERMIT/AGREENl NT FOR A PROCESSION I. Sponsor shall reimburse the Board for the actual cost: to the City for the event, if deemed necessary. 2. Sponsor shall ,provide to the Board a C.ertifteato of Insurance showing a liability policy in full farce and effect with limits of $300,000.00 per occurrence and $5,000,000.00. aggregate and the City of South Bend listed as an additional named insured for this event. 3. Sponsor shall provide to the Board all additional licenses, permits and documentation required for the event. 4. Sponsor agrees to abide by all terms and conditions of the Board's policy governing walks, rubs; parades or other similar event adopted by the Hoard on Much 3, 1985. 5 In. order to ensure public safety during the event, the Board ads to furnish traffic planning, materials, equipment and personnel as deemed necessary by the Police Department Traffic Bureau, the Bureau of Traffic and lighting, and, where applicable, the Board of Park Commissioners. 6. Sponsor acknowledges ihat:the Police Department reserves the right to change this route for safety purposes. 7. In consideration for approval 'by the Board and the use of the sidewalks for the purposes act out above, the undersigned agrees and undertakes to hold the Civil City of South. Bend, Indiana, fits and harmless fiom any :liability leas, costs, costs, damages or, expenses, including attorney fees, which the Civil City of South Bend may suffer or incur, as a result of any claims or actions which may be Haute by any person, including a participant in said activity, arising out of the approval of the request to use the sidewalks indicated in the City of South Bend. The undersigned certifies that hetsha is authorized to bind dx%ubvve mentioned sponsor to the terms hereof- $. Nottflewhin of wrovul/ at of &is teoww will be is med by return of this farusy upon signed autlfarkwien by the Board 4Pghfic Works I understand the above rules and regulatlotts and that this application may be denied based on any false or incomplete inl' urrr adon. Sponsor Signature = T L:,,, Title D OF PUBLIC WORKS APPROVAL _r er Member ADue RETURN FORM TO. rtuard OfNbnc Works 1n6 county-chy Building 227 Wcat Perrargort scaievard SouM Wad, IN 46641 Phone, (574)2,15-425t* Fwc.(574) 235.4171 a-E-Mail: pubHcwk tioWbbcndia,gnv . k.1- CERTIFICATE OF LIABILITY INSURANCE �� TE DA9/6/2D1YYPp 9/6/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must be endorsed. M SUBROGATION IS WAIVED, subject to the terms and Conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endomement(s). PRODUCER NCONTACr Stephen Sxihart Gibson Insurance Agency, Inc. 130 S Main St, Ste 400 P NE , (S00)Sl4-2122 N FAX No: (800)836-2122 C ADoaess: sawihart@gibsonins. cone PO BOX 21177 INSURER AFFORDING COVERAGE NAICIF South Bend IN 46601-0177 INSURER A Cincinnati Insurance Co INSURED INsuRm a Accident Fund Ina Cc Amer 10166 The Stanley Clark School, Inc. INSURERC: 3123 Miami Street INSURER D: INSURER E: South Bend IN 46614-2098 INSURER F: COVERAGES CERTIFICATE NUMBER:16/17 Liab RFVISIONNUMRFR: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LLTR TYPEOFINSURANCE IN80 POLICY NUMBER P C EFF POLICY EXP LIMM A $ COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ® OCCUR SIPOOO8277 7/1/2016 7/2/2017 EACH OCCURRENCE $ 1,000,000 DNNA P ES (En o¢urmnw $ 500,000 MED EXP(Any one pelsm) $ 10,000 PERSONAL& ADV INJURY $ 1,000,000 OENLAGGREGATELIMITAPPIJESPER $ POLICY 0JECT LOL OTHER GENERAL AGGREGATE $ 3,000,000 PRODUCTS-COMP/OP AGO $ 3,000,BDO Employes Senses $ 1,000,000 AVrOMOSILE LIABILITY ANYAUTO AUTOS B"CHEDU5 LED NON-0WNED HIRED AUTOS AUTOS Ea COMBorJde tINED SINGLE LIMIT e $ BODILY INJURY(Perperaon) $ BODILY INJURY(Pen acoMent) $ PROTYDAMAGE PER Pea ' $ $ A $ UMBRELLA LIAR O:CESSUAB $ OCCUR CLAIMS -MADE SIPO000217 7/1/2016 7/1/2D17 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 DEO I I RETENTION $ B WORKERS COMPENSATION AM EMPLOYERS LI UNILBY YIN ANY PROPRIETORIPARTNERIEXECUNVE OFFICERIMEMBER EXCLUDED? ❑NIA (Mandatary in H yea deacdbe under DESCRIPTION OF OPERATIONS blow R076113731 7/1/2016 7/1/2017 PER OTH- STATUTE ER EI.EACHACCIDENT $ SDO 000 E.L. DISEASE - EA EMP $ 500,00 E.L. DISEASE - POLICY LIMB 1 $ S00 000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Addhionol Remarks Sehedub, may ba stashed If mere spew Is required) RE: Clark Run October 22, 2016 City of South Bend 227 W Jefferson Stt South Bend, IN 46601 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Ins Agency/STSWIH All riahts ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 nmamn ♦� ' r w. t, C E o y wr ?? o h � x 6! W � C � y N .� �_ — f � C .9 Q m —� / � - - � -� (�-t- O ry O t.. ,�' .. � v N C � � L: N ��._ b —� 4 � O Un � % F- .�.. i .b... .. �\ 1 • / I Je�" 25 �l � � .� a � ` I ;. C•" ' � �. � r ' � `. Y t \. I 4 L � - v l -• W \ \\ . _.L..__ ]__— _ ��A, �k. ., .� � •�� ,\ i \ 6 �� ,` ,.. < 1 ar J� �I � � T `% f i A`� CERTIFICATE OF LIABILITY INSURANCE DATE 9/6/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME, Stephen Swihart Gibson Insurance Agency, Inc. PNONNo n. (800) 814-2122 AIC Ne: (600)836-2122 130 S Main St, Ste 400 ADDRESS: sswihart@gibsonina. cam PO BOX 11177 INSURERS AFFORDING COVERAGE NAICR South Bend IN 46601-0177 INS URERA:C1ncinnati Insurance Co INSURED INSURER BAccident Fund Ina Cc Amer 10166 The Stanley Clark School, Inc. INSURER C: 3123 Miami Street INSURER D: INSURER E South Bend IN 46614-2098 INSURER F: COVERAGES CERTIFICATENUMBER:16/17 Liab REVISION NUMBER' THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I11511 LTR TYPE OF INSURANCE A DLSURR POLICY NUMBER MM% IDYL LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 7 OCCUR CCURRENCE $ 11000,000 E TO RENTED ES (Ea occurrence $ 500, 000 P(Any one person) $ 30,000 SIP0008277 7/1/2016 NAL$ ADV INJURY W $ 1, 000,000 GEN'L X AGGREGATE LIMIT APPLIES PER: POLICY PRO- ❑JECT LOC AL AGGREGATE $ 31000,000 CTS-COMP/OP AGG $ 3,000,000 ee Benefits $ 11000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO. ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE Per accident $ X UMBRELLA LIM X OCCUR EACH OCCURRENCE $ 10,0001000 AGGREGATE $ 10,000,000 A EXCESS LIAR CLAIMS -MADE DED I IRETENTIONS $ SIP0008277 7/1/2016 7/1/2017 1 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOWPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑NIA (Mandatory In NH) If yes, describe under WCV6113731 7/1/2016 7/1/2017 PER DTH- STATUTE ER EL EACH ACCIDENT $ 500,000 E.L. DISEASE -EA EMPLOYE $ 500,000 EL DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remaras Schedule, may be attached if more space is required) RE: Clark Run October 22, 2016 City of South Bend 227 W Jefferson Stt South Bend, IN 46601 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Ins Agency/STSWIH (C)'1988-201A All rinhfo ro cn n,nd ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 orlun11