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Home My WebLink AboutProcession - South Bend Westside Memorial Day Parade1 E ., 5 _ � �5 TO: FROM: SUBJECT: `•► •: DATE OF EVENT: DATE DUE: FAX OR E-MAIL TO: INTER -OFFICE MEMORANDUM BOARD OF PUBLIC WORKS DATE SENT: 4/26/2017 Ed ieckler, Traffic & Lighting derico Rodriguez, Fire Department Matt Longfellow, Engineering Kara Wood, Park Department Lt. Gene Eyster, Police Department Jill Sciccitano, Downtown South Bend Alarcia Qualls, Streets Legal Department Linda M. Martin, Clerk PROCESSION RECOMMENDATION South Bend Westside Memorial Day Parade Mav 29. 2017 Mav 2. 2017 235-9171 1 Imartin65southbendin.gov RECOMMENDATIONS AND COMMENTS: By Date C?v opo W" ID Sponsor: APPLICATION FOR USE OF PUBLIC RIGHT-OF-WAY FOR PROCESSIONS The Board of Public Works must have FOUR (4)Wy weeks prior notice of the 1 r (Sub i t: ` /G�' O�1 4 Address: &a At City: State: Gip: Phone: 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: - fd p ❑ 'The Board of Public Works must have POUR (4) weeks prior notid 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 , 2017 and no other date ❑ Registration time for the event starts at5Q rr Ip.m. ❑ Starting time of the procession is G ��a m /p.m. �, ❑ Estimated completion time is`L a,rn(p.r. This event involves the use of the following roadways Ef This event involves City streets ❑ This event involves County roads ❑ This event involves State highways ❑ This event involves use of a park (Must obtain permission from Park Board) 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 meeting) [� This event involves the use of the sidewalk ❑ Participants must stay on the sidewalk and obey all traffic laws. 0 This event is a loca regional/national event (Please circle the appropriate event type) ❑r This event will be coordinated with the property owner/business where staging will take place Updated 4/06/16 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's 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 helshe is authorized to bind the above mentioned sponsor to the terms hereof, S. Notification of rapprovalldenial of tlds regaaevt ivill he issued by return of thiv form, aaporr signed authorization by the Board gfPub ie Works I understand the above rules and regulations and that this application may be denied based on any false or incomplete information. �a-z Sponsor Signature ! i/ % j( Printed Name UA A(' L Title A" K- WaA4 BOARD OF PUBLIC WORDS APPROVAL President Me ber Member Mcmbcr 7 Member Date RETURN FORM TO: 2 Board ol'Publie Works 1316 County -City Building 227 West Jefferson Boulevard South Bend, IN 46601 Phone: (574) 235-9251 eFax: (574) 235-9171 o E-Mail: publicwks 4soulhbendin.gov �,"��QD nATE (MW-DFYYYY] CCERTIFICATE OF LIABILITY INSURANCE 4/25/2017 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 pallcy(las) 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 certiflcate does not center rights to the certificate holder In Ileu of such endorsemont(s), PRODUCER Surplus Insurance Brokers P . 0. BOX .14 g South Bend IN 4 6 624 --0� 4 9 CO AC * * * NAME: AFCNNo' Exl : FAX Ho E-MAIL ADDMS$: WSURERIS AFFORDINGCOVERAGE NA€C# _ INSURER A! CAPITOL SPECIALTY INS CORM 10328 _ INSURED SOUTH BEND MEMORIAL DAY PARADE 14985 ADAMS RD INSURERR: INSURERD: GRANGER IN 46530 INSURER E : INSURERF; COVERAGES CERTIFICATE NUMBER: 00087675 REVISION NUMBER: 00087897 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 MAYHAVE BEEN REDUCED BYPAID CLAIMS, INSR LTR TYPE OF INSURANCE IN 3 POLICY NUMBER IdMI�OFYYY PP MMIODIYYYY LIMITS A i COMMERCIAL GENERAL LIABILITY CLAIMS -MADE EX]OCCUR IMPOO13001000481 5/29I2p1'! 5/36/201! .EACHOCCURR♦:NCE PREMISES(Eaocrencel_ 3 1,000,000 S 100,00Q IAEDEXP(An onope[aon) $ 5,000 _ PERSONAL& ADV INJJRY $ 1,000,000 GEMLAGGREGATE LIMIT AP€OESPER: GENERALAGOREGATE $ 2,000,000 - X POLICY ❑ P O LOC PRODUCTS -COMPIOPACG $ INCLUDED $ OTHER' AUTOMOBILE LIAWLITY COM8INEDS€N LELUdIT En acgdenl $ BODILY INJURY (Per poison) S ANY AUTO T UWi9ED SCHEDULED AUTOS ONLY AUTOS HIRED NON-OV55JED AUTOS ONLY H AUTOS ONLY BOD€LY II4JURY (Pet aocidont) $ PROPERTY€IAMAGE Per accidonl $ i UhIRRELLALIAB OCCUR EACH OCCURRENCE ; AGGREGATE EXCESS LIAB. CLAIMS-IADC _ TIED RETENTION$ 3 WORKERSCOMPENSATION AND EMPLOYEW LIAB14ITY Y/N ANYFROPRIETORIPARTNUVE) :CUTIVE STATUTE ER E.L. EACH ACCIDENT 4 OFFICEMMEMBERD(CLULkM (Mandatory In NH) NIA F..I..DISFASE-EAEMPLOYEE —..-.__,.__._.....__.._..._ $ E.L. DISFASE -POLICY LIMIT $ IfYes, deser�h0 under DESCRIPTION OF OPERATIONS be€or, DESCRIPTION OF OPERAT€ONS I LOCATIONS F VEHICLES (ACORD 101, Additional Remarks Schedule, may be altae hod Irmoro space Is required) SOCIAL GATHERINGS/MEETINGS CITY OF SOUTH BEND BOARD OF PUBLIC WORKS 227 W JI FFERSON BLVD ROOM 1316 SOUTH BEND IN 46601 UTAN ULLIAI INN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOR€tE3 REPRESENTATIVE Co] ON. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD (OMNI7 CERT004-170113l1704251120)