Loading...
HomeMy WebLinkAboutNon Res Block Party - The Well at River Park Grace.^.fit • _ T`. o' iir�.;�--'. . fiR Yam-- i CV x r3 �w REA '-� vww� Tw M , a 'Wvp�mj A M it, � rIl I IMM 17TIFT, 777 71;11 v V� " Ife- v �' �lq '� a. Certified Check or Money Order in the Amount of $125.00, or: b. For Certified Nonprofit Organizations: Copies of the 501(c)(3) Internal Revenue Exemption Status Document and a current copy of born 990 of Form 990-CZ. are included with this application, Yes No and additionally filed with the Office of the City Clerk, 01 Floor, County -City Building, 227 W. Jefferson Blvd., South Bend , Indiana. c. Certificate of Insurance d, Maps, drawings of the area and setup plan Yes No a. This event involves City streets Yes No h. This event involves County roads Yes No ' c. This event involves State highways Yes No d. This event involves the use of the sidewalk Yes (!0) e. This event is a localtregionailnational event (Please circle the Yes No appropriate event type) Ne& f—:� \/(?-Y" f. Affected property/business owners have been notified of this event. No g. I understand that I must arrange a meeting with all affected governmental agencies to organize the above event (Call Marcia Qualls, Customer Service Manager, 235-5939 to organize Yes T, No meeting). IF ALCOHOL 1S TO BE SERVED OR SOLD Alcoholic beverages will be served Alcoholic Leverages will be sold Certified Check or Money Order for $400.00 must be submitted with application, ' Application cannot be processed without deposit. ' Deposit will be returned upon inspection of event area by the Board of Public W'orks. Names and phone numbers of THREE security guards • To monitor underage drinking. Qualifications must he listed (e.g. Off -duty police officer, professional security guard, or event APPIKANT). .A drawing must be submitted showing: Fencing around serving area Trash receptacles. O Ample trash receptacles must be provided to ensure proper disposal of refuse. Temporary liquor license. ' Call the Alcohol & Tobacco Commission at (317) 234-4315 for more information. 6 Application cannot he processed without a copy of this license. City of South Bend, Indiana + Board of Public Works PERMIT AND AGREEMENT FOR THE USE OF THE RIGHT-OF-WAY FOR NON-RES]DENTIAL BLOCK PARTIES The Non-residential Block Party will be permitted to take place tinder the following terms and conditions: I . Pursuant to Local Ordinance No, 10224-13, there is a S 125,00 non-refundable fee for non- residential Block Parties. Non-profit organizations meeting Section 501(c)(3) of the Internal Revenue Code are exempt from the fee provided copies of the 501(c)(3) Internal Revenue Exemption Status Documcnt and a current copy of form 990 of Form 990-EZ are filed with this application and with the Office of the City Clerk, 4th Floor, County -City Building, 227 W'. Jefferson Blvd., South Bend , Indiana. 2. The APPL.ICANI' must comply with all terms and conditions of this Permit and Agreement. 3. The APPLICANT shall reimburse the Board for the actual cast to the City for the event, if deemed necessary. 4. APPLICANT shall include a flyer or letter describing the details of the event, 5. Notification of approval/denial of this request will be issued by return of this form, upon signed authorization by the Board of Public Works. 6. The APPLICANT shall provide to the Beard a Certificate of Insurance showing. a liability policy in full force and effect Nvith 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. 7. The APPLICANT assumes full responsibility for providing, ample disposal containers for refuselrecycling and assures the area will be cleaned up upon the conclusion of the event. 8, Barricades will be delivered and picked up at the event location. The APPLICANT is responsible for seeing that all cones are maintained and returned undamaged. 9. The APPLICANT will follow the City of South Fiend Noise Ordinance, which is in effect at all hours. Between the hours of 11:00 p.m. and 7:00 a.m. certain noises are particularly prohibited. These include operating radio receiving sets, musical instruments, phonographs and other sound reproduction devices if audible fifty (50) feet away, as well as shouting, yelling, hooting, whistling, or singing in the streets in a manner to disturb the peace (Municipal Code 13-57). 10. The APPLICANT assures the City that the area will be closed during the tinges indicated on the application only. Event end times are pursuant to the reconrzuendations of the South Bend Police Department. 11, IF ALCOHOL IS TO BE SERVED OR SOLD a Certified Check or Money Order for $400,00 must be submitted with application. The application cannot be processed without a deposit. The deposit will be returned by the Board of Public Works upon inspection of the event area after the event, and provided there is no damage to the area. Names, phone numbers, and qualifications (e.g. Off -duty police officer, prnf'essiotral security guard, or event APPLICANT) of Tl4REE security guards to monitor underage drinking, must be submitted 4 with the application. A drawing must be submitted showing fencing around serving area, and trash receptacles. For a temporary liquor license call the Alcohol and "Tobacco Commission at (317) 234-4315 for more information. Application cannot be processed without a copy oi'this license. 12. APPLICANT agrees to indcmnify, defend and hold harmless the Civil City of South Bend, Indiana, from any liability. loss, costs, damages or expenses, including attorney lees, -,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 the activity. arising out of the approval of this request by the Board of Public 1X`orks to close a portion of the public right-of-way for the event described above. I have read the Application and Permit and the Agreement for time '`i_'se of Right -of -Way for Special Events" and I understand and agree to the above rules and regulations. I also understand that this appheation may be denied based on any false or incomplete infonnation. Dated this day of 2U APPLICANT Signature C Printed Dame BOARD OF PUBLIC WORKS APPROVAL Pre. 'dent Mernber Member RETURN FORM TO; Board of Publie 1Vorks Member / Date 1316 County -City Building 227 West Jefferson Boulevard South Fend, IN 46601 Phone: (574) 235-9251 • Fax: (574) 235-9171 a E-Mail: pub]iewks,. southbendin.gov Event Details: Date: May 30th Time: 5:00-10:00 Location: 2410 Mishawaka Ave, South Bend Indoor Activities: Superhero Trivia Night Table Top Gaming Room Magic The Gathering Tournament Pickapart Improv Comedy Live Original Music Costume Parade and Competition "She Kills Monsters" Play - Clay High School Indoor Booths: Dragon Script Bracelet Making Booth Make Your Own Cape by MakeSouthBend Vendors tables Outdoor Options: Waffle Wagon Food Truck Outdoor Activity: Nerf War - Hosted by Evangel Heights OP ID: EIS ACIEWO EVIDENCE OF COMMERCIAL PROPERTY INSURANCE TE F�011101��` lriorzfala THIS EVIDENCE OF COMMERCIAL PROPERTY INSURANCE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ADDITIONAL INTEREST NAMED BELOW. THIS EVIDENCE DOES NOT AFFIR1 ATPJELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS EVIDENCE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE ADDITIONAL INTEREST. PRODUCER NA ' PI4ONE -2 -5555 tAfC. Ne, Ex3 COMPANY NAME AND ADORE" NAI C ND: 13528 ACT &ON AND DRESS ;,, yopul ' nsurance 'coup mm Brotherhood Mutual Insurance 1900 Jackson Road PO Box 2227 Mishawaka, IN 46644-9195 Fort Wayne, IN 49801.2227 Nathan D Spite IF MULTIPLE COMPANIES, COMPLETE SEPARATE FORM FOR EACt1 A!C No : �74-268 9177 ADDREss N CODE: 00315 stub ODDS POLICY TYPPE Commercial Package cOETCY RIVEpRpRIE4gq ) n^......... �_ NAMED IN5UREp1AN@TK -.LOAN NUMBER -..�_ � � P()t.i!NLMSER=Asffhley tifdCe TSwanson 13M - 2410 Mishawaka Avenue South Bend,1N 46616 EFFECi(NEDATE -.. EXPIRATION DATE CONTINUM UNTIL 01/16/14 11114114 TERM3NA7ieDIFCHEC4 THIS REPLACES PRIOR RMENCE DAIEZ): ,... ADDITIONAL NAMED INSURED€91 .-..�.- PROPERTY INFORMATION Use REMARKS On R910,4, IT MOrO Space IS r utrea ...- r.ATIQ�I! DESCRIPT O" GlxasroomfArtnex 2416 M , 'ka Avenue South Bend, IN 466115-21,15 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 WfTH RESPECT TO WHICH THIS EVIDENCE OF PROPERTY INSURANCE 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, VV•LMVb fief Vf�11,�.iv.. i-i.r„ry n-v••.�� ••-�•� -- - - -- - - COMMERCIAL PROPERTY COVERAGE AMOUNT OF INSURANCE: $ 601,000 DIED: 1,000 ...... ... �.p,Y E8 NO WA © BUSINESS INCOME © RENTAL VALUE X If YES, LIMIT:. Actual Loaa 5ustalned; 4 of nm3nfhs; BLANKET COVERAGE X If YES, indicate values) repoded on ptoperty identified above: S TERRORISM COVERAGE _ X Attodr Disclosure Notioa f DEC IS THERE A TERRORISMSPECIFIC EXCLUSION7 .w..�. IS DOMESTIC TERRORISM EXCLUDED? .X X - LIMITED FUNGUS COVERAGE - a If YES, LIMIT: DED: FUNGUS EXCLUSION Of "YES', apoorfy organ€ Ban's forTn used) i REPLACEMENT OOST X AGREED VALUE X COINSURANCE - X If YES, 100% EQUIPMENT BREAKDOWN Of Applk�Qbla) I X If YES, LIMIT: ORDNANCE OR LAW - Covetage tof €ass to undamaged portion of bkSg X If YES, LIMIT: DED. OamolNon Costa X If YES. LIMIT; DED: Ina. Cost of Cons Winn - X If YES. LIMIT; DED: EARTH MOVEMENT of Applkabto) X If YES, LIMIT: DED: FLOOD (N Appticabla) X If YES, LIMIT: DED: WIND 1 HAIL (If Sub)eet to Different Prmbmna) 6 X If YES, LIMIT: DED: - PERMISSION TO WAIVE SUBROGATION IN FAVOR OF MORTGAGE HOLDER PRIOR TO LOSS X _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE: EXPIRATION LIA It IHPKr-vt-, NV Ilk c VVI" nc DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, rnelxTchc I I CONTRACT OF SALE NAME AND AD00 6SS Lake City Bank - Warsaw Wox 13_$7 Warsaw,1 46681.1387 cc —on—" f7Ai?J1il LENDER SEIWVC NG AGENT NAME AND ADDRESS AUFHORUED REPRESENTATINE p ILIb ....................... Pace 1 of I rn 2003-201 t ACOP.D COP.PORATION. All rights resen�ed. Indiana Dcparimcnl cif ReNcnttc fndi;ma Govc'ranivnl Center Notth 111dian;tl10lik. 1st liana 16204 lndiarta Nonprofit Sales Tax Exemption Certificate r• I fhls cerlrllcatc may not lw trtied (o collezt ,ales taxi Form N l'-, I State Form 510(15 TID: 0146012836 t 4-{lI LOC: 000 Corresp ill: 1300097912795 Issued: 03/15/2013 1300097912795 ifilil I11111111lN ILINER1111111Hall "in III RIVER PARK GRACE CHURCH INCORPORATED 2410 MISHAWAKA.AVE SO UT1i BEND, IN 46615-21 45 Or,lanizaliotl is only exempt from payment of safes tax on Purchase, for which the or.-anization is grtlrltcel exerllpliOn. ................................. ......... ......... —••-,..._._.................,......,..........,.............,.... (Detach Here) (,qualifying for sales tax exrinption requires the completion anti filing of an application form prescribed by the Indiana Departmetlt of Rovoiwe. The laxpavcr ldentiliculion Number (TiD) ahovc must be prns,ided ul the n:tailer il'purch;lses are to fx exempt Front latex LUX. In addition, to yualil*y for subs tax exemption. such purchases mu l be used for purposes described in Information Bulletin #10, The TID mu,t be usc(1 (in Sales Tax Exemption Certificates 4ST-105i wlwn makini,. qualified purchases. The (act that an organization is granted exemption from income: tax by the fc(leral government, or (lilt it at one time was granted such an exanlp6on by the: State cif Indiana. does not noccessarify mean that a purchase made by a nonprofit orgartization is-cxen1prft6m sale, lax. Requirtapicwts for Sales Tax Fxempi Purchases by Nonprofit ❑rganizations: A. Purchases by a Nonprofit Organization for its Own Usi.: ] , In order to (It#ahfy for sales tax oxemplion on purchases. a nonprofit'organization, must satisfy the follOWin., la) '11w organization oust be named or described in IC. 6-15-5-2 11 b). Organizations named or docrib�d in thi, CO& >ecliors are 01'LiMiied and Operaird c:.xclusi+aly for cute or snore of the f'c11len+in�� purposes: Cisic Chal'it;%blc Educational Fraternal L.iwrm-v RclNious Scientific (b) Included in the above general organizational calvvorics are the following specifically named types obnonproCit orgunizarions: Bu.+iness i_.e Loss Churches Converlt.s Fraternities Labor unions Licecv d Hospitals monasterfc> Parochial Schools Pension fresh Shared Hospital Services Sororities Student Cooperative Housino I j In order to quality for sales tax exemption. purchases must he used for the same purposes for which the nunprolit organizati(ln is aranleel exemption. z, Peirchav'v for the private benrfir oJ'an), member, rfireclor. or r)fficer <, he rrouprc,fir car Jiu'ruts ullrc'r buliviclncal arc° frol eligible fiw esrrrrjrriorr. purch ayes snarl( for socfai purpose's are never v.venfpr. $. Purchases by Nonprofit Or-unization for Resale; Purchases of tangible personal prollerty purchased for resale lay nonprofit or,,anizations are eli,ible for sales t.tx exe rription.