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Home My WebLink AboutProcession - YMCA of Michiana'7777�- - n an n APPLICATION FOR USE OF PUBLIC RIGHT-OF-WAY FOR PROCESSIONS The Board of Public Works must have FOUR (4) weeks prior notice of the Sponsor: 'YMCA of Michiana Address: 1201 Noilhside Blvd City: South Bend State: IN Zip: Submitted By: Dani Elgas 46615 Phone: 5742879622 Sponsor may use the public right-of-way described as (describe route and attach map) Northside Blvd from Riverview Family YMCA towards Ironwood, onto Pleasant, right on 27th, down to Pleasant then turn around at dead-end. before Logan PLEASE NOTE: THE SOUTH BEND POLICE DEPARTMENT RESERVES THE RIGHT TO CH GE YOUR ROUTE FOR ySAFE TY PURPOSES Event name: � *a— '1 7 (- I' CAN 1 GQn 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 SEPTEMBER 24...................., 2017 and no other date ® Registration time for the event starts atC , a.m./ .m. ® Starting time of the procession is a.m./p.m. ® Estimated completion time is 12 a,m./p.m. This event involves the use of the following roadways ® This event involves City streets ❑ This event involves County roads ❑ This event involves State highways ® I understand that I crust 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 ---> ljo uxt o 01 Po nk a Pe ct-- ® Participants must stay on the sidewalk and obey all traffic laws. ® This event is a local/regional/national event (Please circle the appropriate event type) ® This event will be coordinated with the property owner/business where staging will take place Updated 6/25/12 PERMITIAGREEMENT 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 f mish 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. Not Heaton of approval/denial of dils request ►vill be issued by return of dih forme, upon signed autleorization by the Board of Public Works I understand the above rules and regulations and that this application may be denied based on any false or incomplete information. Sponsor Signature Printed Name .� D( en I %ax Title BOARD OF P LIC WORDS APPR( M er � Z / Member rum Member 1 o �% 7 Date RETURN FORM TO: Board of Public Works 1316 County -City Building 227 west Jefferson Boulevard Soutb Bend, IN 46601 Phone: (574) 235-9251 s Fax: (574) 235-9171 o E-Mail; publicwks@southbondin.gov southbendin.gov 2 :3 z 4 i � I �a tl F 5 YMCAO-2 OP III: TJ 4.. I CERTIFICATE OF LIABILITY INSURANCE D 0711 1201 YY) o7r12r2a1s THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO FLIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMA71VELY 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(tes) must be endorsed. If SUBROGATION 15 WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this cerlilicato does not confer rights to the certificate holder in lieu of such endorsements . caNrA PRODUCER NAME: TCU Agency, LLC PHONE u 426 Lincolnway East MAIL Mishawaka, IN 46544 ADD":ss• GaryD.Wlesel -`tN$URP- gIAFFORo1NGCOVERAGE MMIMMR A -National 5aeciaity Insurance INSURED YMCA ofMlchiana. I suRERs: 1201 Northside Blvd. INsuRERa: South Bend, IN 46616 — — - - —THIS.IS TS3CERTIFI' Tk3AZ.iI�E.PCZiCCIES_OFJL1541FiflNl h )j:.l..tl�.It3»SZ6v.oGGIV_...._.r .--.-s_. INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT Ta 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. IN R AD PO C EFF POLCYExP LIMITS 7YPEOFINSURANCE POLCYNU UMBER .MMfD DD EACH o (3ENIsRALL1ABELITY r.GURRIrP10E 1,UO0,i 5 A X COMME ACIALGENERALLIASILITY 3( NSE 21Q4469 0710112018 0710112017 PREMSE= OLQUIF Ice $ 100,[ CLAMS -MADE � OCCUR MED EXP one person)$ri _........_. a nnn r A A A NIA N5F2104409 iUUp2104480 CF291$934 NSF2113693 0710112010 07101l20190710112Q17 07101/2016 0710112018 0110112017 0710112017 071o112017 GENERALAGGREGATS S a PRODUCTS-COMPIOPAGO S-71 1 GEN'LAGOREGATEUMR'APPLIES PER., POLICY PRO LOCI AUTOMOBILE LIABILITY 3C ANYAUTo ALLOWNEDk8AUTOS AUTOS: HIRED AUTOSX UMBRELLA LIAR EXCESSLIAS Emp Bon, COMBINED 51NG E; LIMU a den S 1 3 BODILY INJURY (Per parson) $ BODILYINJURY(Per accident) $ EORACCI EACH OCCURRENCE $A AGGREGATE $ �p X QRYL.E � ER $ WORKERS COMPENSATION ANDEMPLOYERS'LMILITY OOFFRCUR/PMEMBERPEXcLcLUnID?ecunvE Y� (MandatoryIn NH) IIMy.RI"r11nu"do, DE6L'RiPiION OP OPERATIONS Lelow jMl Auto Coverage E.L,EACH ACCIDENr $ E.L,tHSEASE-EA EMPLOYE $ E.L.13MLASE-PO€IUYLIMIT Liability $ , 1 DESCRIPTION OF OPERATIONS I LOCATIONS ivEHICLES (Attach ACORD 101, Addltlonal Remarks Schedule, If Mare space IS required) -The City of South 38end and the Board o;ff paik Commisoioners are additional i.nsuredra on the general liability in accordance With all terms, conditiona & limitations o:E the policy and then only with respect to the Michiana 3 for 3 Triathlon. City of South Bend Board of Public Works 227 W. Jeffferson Blvd. 1200 County -City Building South Bond, IN 46604 ACORD 25 (2010T05) CITYSBB SHOULD ANY OF THE ABOVE D>SCFiIBEwO POLICIES BE CANCELLED BEFORE THE: EISPERATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTA71VE 01988-2010 ACORD CORPORATION. All rights reserved. "The ACORD name and logo are registered marks of ACORD