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HomeMy WebLinkAboutProcession - Dean Alvis - March for Science South Bendi� ��-.•4�' .. �•.--. - j��. - - -. -�.. _.:'rr --��+`i�- -�' ";G'-- � h - �-. �:� -'-fit .r.�` . r� Sponsor: APPLICATION FOR USE OF PUBLIC RIGHT-O&WAY FOR PROCESSIONS The Board of Public Works must have FOUR (4) weeks prior notice of the Dean Alvis Address: 1411 Sunnymede Ave City: South Bend State: IN Submitted By: Dean Alvis Zip: 46615 Phone: 574-233-4954 Sponsor may use the public right-of-way described as (describe route and attach map) PLEASE NOTE: THE SOUTH BEND POLICE DEPARTMENT RESERVES THE RIGHT TO CHANGE YOUR ROUTE FOR SAFETY PURPOSES Event name: March for Science South Bend ❑ The Board of Public Works must have FOUR (4) weeks prior notice 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 ❑ The event shall be held on April 22 , 20 17 and no other date Registration time for the event starts at 2:00pm.m./p.111. ❑ Starting time of the procession is 2:45prtI.m./p.m. ❑ Estimated completion time is 4::00 na.m./p.m. This event involves the use of the following roadways I In This event involves City streets This event involves County roads This event involves State highways - just crossing St. Joseph at Colfax. This event involves use of a park (Must obtain permission from Park Board) I understand that I must arrange aITOting with all affected governmental agencies to organize the above event (Call Marcia Qualls, Customer Service Manager, 235-5939 to organize meeting) © This event involves the use of the sidewalk ® Participants must stay on the sidewalk and obey all traffic Iaws. This event will be co Tonal ent (Please circle the appropriate event type) with the property owner/business where staging will take place Updated 4/06/16 1 PERMIT/AGREEMENT FOR A PROCESSION 1. 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 Certificate of Insurance showing a liability policy in full force 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® policy governing walks, runs, parades or other similar event adopted by the Board on March 3, 1985. 5. In order to ensure public safety during the event, the Board agrees 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 that 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 set out above, the undersigned agrees and undertakes to hold the Civil City of South Bend, Indiana, free and harmless from any liability loss, 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 made 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 he/she is authorized to bind the above mentioned sponsor to the terms hereof, 8. Notification of approval/denial of this request will be issued by return of this form, upon signed authorization by the Board of Public Works I understand the above rule nd regulations and that this application may be denied based on any false or incomplete i o ation. Sponsor Signature, Printed Name Dean Alvis Title member of organizing group for the march BOARD OF PV LIC WO S APPROVAL 44'i'j PresideV V YMember tuber Member Member Date RETURN FORM TO: 2 Board of Public Works 1316 County -City Building 227 West Jefferson Boulevard South Bend, IN 46601 Phone: (574) 235-9251 ❑ Fax: (574) 235-9171 ❑ E-Mail: publiewks r�southbendin.gov A C14.. >R" , - CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 04/19/2017 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(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: PH�N E ; (574) 287-8704 wC No): (888) 214-5881 McCartney Insurance, LLC 1402 Portage Ave. EDMDAIpSS:IL rnCCarfneylnsuranCe@comcast.net INSURERS AFFORDING COVERAGE NAIC # South Bend, IN 46616 INSURERA : Westchester Phone (574) 287-8704 Fax (888) 214-5881 INSURED INSURERS: INSURER C : Dean Alvis INSURER D : 1411 sunnymede ave South Bend IN 46615 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 13ELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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. TYPE OF INSURANCE ADDILTRR NSR WVD POLICY NUMBER MM1pnYYY M€OVIIDDNYXI'PY LIMITS A COMMERCIAL GENERAL LIABILITY ❑ CLAIMS -MADE +/ OCCUR ❑ - SEV7534g2017 04/22/2017 04/24/2017 EACH OCCURRENCE $ 1000000 PREMISES (EaDAMAGE TO Eoccu RENTED $ 100000 MED EXP {Any one person $ 1000 ❑ PERSONAL & ADV INJURY $ 1000000 GEN'L AGGREGATE LIMIT APPLIES PER: ❑ POLICY ❑ JECOT- ❑ LOC ❑ OTHER GENERAL AGGREGATE $ 2000000 PRODUCTS - COMP/OP AGG $ 2000000 $ AUTOMOBILE LIABILITY ❑ ANY AUTO OWNED SCHEDULED ❑ AUTOS ONLY AUTOS ❑HIRED ❑ NON -OWNED AUTOS ONLY AUTOS ONLY ❑ ❑ CEO MBIINd DLSINGLE LIMITarci $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per. $ $ ❑ UMBRELLA LIAB ❑ OCCUR ❑ EXCESS LIA13 ❑ CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ ❑ DED ❑ RETENTION $ $ WYW WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUT[VE[ ] OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N!A ❑ PI=R TUTE OTH- I 1 E,L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) City of South Bend additionally insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of South Bend THE EXPIRATION DATE. THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) QF The ACORD name and logo are rogistered marks of ACORD