TAB 4

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SPECIAL FUNCTION PERMIT APPLICATION toEVENT NAME EVENTDATESGN 2 S opAPPLICANT EVENT TIME my cao

ADDRESSl c PHONE S33

CONTACT im B S PHONE

DETAILS OF FUNCTION LOCATION PARADE ROUTE ETC cst Uoct out oE

ANTICIPATED ATTENDANCE

CITY SERVICES REQUII2ED lPOLICE Streets Blocked Traffic Control Security OtherPUBLIC WORKS Barricades Cleanup Setup Other

If a temporary restroom is utilized for aperiod greater than five S days a Temporary Use Permit is requiredApplication is available at City Hall

TEMPORARY RESTROOM FACILITIES ofunits ofdaysProposed locations

INSURANCE REQUIl2EMENT Insurance naming the City ofPalmetto as an Additional Insured must beprovided to the City Clerk ten 10 days prior to any event thatispart ofthe Special Function Permit

Please review Exhibit A for insurance coverage requirements To purchase insurance policies of appropriatecoverage through the City please complete and submit the Special Events Application Quote Form Exhibit B

The Special Function Permit Application must be submitted to City Clerks office at least 30 days prior to theevent

Sale or consumption of alcoholic beverages on City property is strictly prohibited

Ifyour event will include the use of loudspeakers you may be required to apply for a Special Permit Exceptionto the Citys Noise Ordinance See Chapter5Amusements ofthe City ofPalmetto Code ofOrdinances

THIS PORTION OF THE PAGE INTENTIONALLY LEFT BLANK

PLEASE CONTINUE TO PAGE 2

Special Function Permit ApplicationPage 2

EVENTfi

2 Event DateSuN 2LS2o

l HAVE READ AND UNDERSTAND THE ABOVE SPECIAL FUNCTION PERMIT APPLICATIONCONDITIONS

CITY APPROVAL

Public Works Director

Risk ManagementParks DepartmentPolice DepartmentNorth RiverFire

APPROVED BY C SSION

Internal use onlyDate Received

Date lDate

Date

Date

Date

Date

i

r ow NQFZ Conae f

CIZR

d9O

SPECIAL FUNCTION PERMIT APPLICATION

EVENT NAME stival ChildrsnsPomade

APPLICANT I de Soto Historical Society Tic

ADDRESS 910 Third A p tRrrlPntm Fi 3421Y

CONTACTgMunutivelitertnr

EVENT DATEApril 22 x011

EVENT TIMEi 1000 an 300n

PHONE X17471

PHONE cyF71E7l

DETAILS OF FUNCTION LOCATION PARADE ROUTE ETC Use of Suttcn andIParirs

for Iii1 clrnn G antintiti TIof oan arrlmglA7P371tGlibSatfiarhrx

ANTICIPATED ATTENDANCE

CITY SERVICES REQUIREDPOLICE Streets Blocked X Traffic Control Security OtherPUBLIC WORKS Barricades X Cleanup Setup Other

See attached parade route of strreets blockedIf a temporary restroom is utilized for a period greater than five S days a Temporary Use Permit is requiredApplication is available at City Hall

TEMPORARY RESTROOM FACILITIES ofunits

Proposed locations

INSURANCE REQUIREMENT Insurance naming the City ofPalmetto as an Additional Insured must be

provided to the City Clerk ten 10 days prior to any event that is part ofthe Special Function Permit

Please review Exhibit A for insurance coverage requirements To purchase insurance policies of appropriatecoverage through the City please complete and submit the Special Events Application Quote Form Exhibit B

The Special Function Permit Application must be submitted to Ciry Clerks office at least 30 days prior to theevent

Sale or consumption of alcoholic beverages on City property is strictly prohibited

Ifyour event will include the use of loudspeakers you may be required to apply for a Special Permit Exceptionto the Citys Noise Ordinance See Chapter5Amusements ofthe City ofPalmetto Code of Ordinances

THIS PORTION OF THE PAGE INTENTIONALLY LEFT BLANK

ofdays

PLEASE CONTINUE TO PAGE 2

Special Function Permit ApplicationPage 2

EVENT De Sago HettspI9titralClliclene PAeade Event Date Apii2 x011

I HAVE READ AND UNDERSTAND THE ABOVE SPECIAL FUNCTION PERMIT APPLICATIONCONDITIONS

Permittee te Sotaoe PtesiciaC10y3lA

CITY APPROVAL

Public Works Director

Police DepartmentNorth River Fire

APPROVED BY MMI SIGN

Internal use onlyDate Received

Date UDate

Date

Date

To City CommissionThru Diane Ponders Assistant City ClerkFrom Geoff Seger Parks Director

Subject Desoto ChildrensParadeDate of event Apri122 2011

Desoto ChildrensParadeParade and event held at Sutton and Lamb Parks The Parks Department will be

responsible for the closing ofroads along the parade route detouring traffic aroundthe parade route and reopening after the event is over During the event the staff is

responsible for debris removal and clean up when the event is over

Labor 6 hrs

Bobby Jackson 7191Victor Pompey 7461

Equipment used3 Public Works trucks @ 750 per hour 6750150 Safety Cones 35 directional signs

Rental Fee for Sutton Park1000am 300pm 10500

Total cost 31902

r 1 9 t

e9 moo

SPECIAL FUNCTION PERMIT APPLICATION

EVENT NAME

APPLICANTTTarrrclP Sri Hi4trni1 iriPty Tm

ADDRESS 910 Third AvenaeWest tcn FL 34205

CONTACT Stern MrLym eaitive Dlxector

EVENT DATE Apri 30 x011

EVENT TIME 615 pn 1100pn

PHONE17471998

PHONE9417471998

DETAILS OF FUNCTION LOCATION PARADE ROUTE ETC Status at Hawkins Staclitm Fxooaeds Est

onNbnatee Avep ids at fitDisuses cnInatee Avaaaebetwaeri 9th St an31stStSattaclierl mm of h p Parxl mitr

ANTICIPATED ATTENDANCE

CITY SERVICES REQUIREDPOLICE Streets Blocked Traffic Control X Security OtherPUBLIC WORKS Barricades Cleanup Setup Other

If a temporary restroom is utilized for a period greater than five 5 days a Temporary Use Permit is requiredApplication is available at City Hall

TEMPORARY RESTROOM FACILITIES of units

Proposed locations

INSURANCE REQUIREMENT Insurance naming the City of Palmetto as an Additional Insured must be

provided to the City Clerk ten 10 days prior to any event that is part ofthe Special Function Permit

Please review Exhibit A for insurance coverage requirements To purchase insurance policies of appropriatecoverage through the City please complete and submit the Special Events Application Quote Form Exhibit B

The Special Function Permit Application must be submitted to City Clerks office at least 30 days prior to theevent

Sale or consumption of alcoholic beverages on City property is strictly prohibited

If your event will include the use of loudspeakers you may be required to apply for a Special Permit Exceptionto the Citys Noise Ordinance See Chapter5Amusements ofthe City ofPalmetto Code of Ordinances

THIS PORTION OF THE PAGE INTENTIONALLY LEFT BLANK

of days

PLEASE CONTINUE TO PAGE 2

Special liunction Permit ApplicationPage 2

EVENT ISato IiestsQe sttval wand Parade Event Daterr1 f111

I HAVE READ AND UNDERSTAND THE ABOVE SPECIAL FUNCTION PERMIT APPLICATION

CONDITIONS

Permittee Gus Sokos President 101410

CITY APPROVAL

jPublic WorksDuector6eGEcCPolice DepartmentNorth River Fire

APPROVED BY C SION

Internal use onlyDate Received

Date

Date

Date 0Date

To City CommissionThru Diane Ponders Assistant City ClerkFrom Geoff Seger Parks DirectorRe De Soto Heritage ParadeDate of Event Apri130 2011

De Soto Heritage Festival Grand ParadeThe Parks Department will be responsible for the closing ofthe Green Bridge and for thesafe detouring ofnorth and south bound traffic for the duration of the parade Theassociated costs are as follows

In Kind

19 48 traffic signs see map for locations25 36 safety cones FDOT approved to close the Green Bridge PPD to monitor

LaborEquipment 3 HoursJim MichenerBobby Jackson

City Truck

908171912250

Total 18522

CI nt 2131 HERNADESle

ACORDTM CERTIFICATE OF LIABILITY INSURANCE 02032010

PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION

Haas Wilkerson Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE

HOLDER THIS CERTIFICATE DOES NOT AMEND EXTEND OR

4300 Shawnee Mission Parkway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW

Fairway KS 66205

913 4324400 INSURERS AFFORDING COVERAGE NAIC

INSURED INSURER A ACE American Insurance Co 22667

Hernando de Soto Historical Society INSURER B

Inc dba De Soto Heritage FestivalINSURER C

910 Third Ave WINSURER D

Bradenton FL 34205INSURER E

COVERAGES

THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING

TERM OR CONDITION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TOWHICH THIS CERTIFICATE MAY BE ISSUED ORANY REQUIREMENTMAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH

POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS

DDVETEYDTIONICY EPIpPpL LIMITS

LTR NSR TYPE OF INSURANCE POLICY NUMBER MMA M DA

A X GENERAL LIABILITY 620661902 013010 013011 EACH OCCURRENCE 1 00 00DAMAGE TO RENTED 500 D00X COMMERCIAL GENERAL LIABILITY

CLAIMS MADE OCCUR MED EXP Any one person EXCLU DED

PERSONAL ADV INJURY 1 000 00

GENERAL AGGREGATE 5 000 00

GENLAGGREGATE LIMIT APPLIES PER PRODUCTS COMPOPAGG 5000 0

POLICY jECOT LOC

AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT

ANY AUTOEa accident

ALL OWNED AUTOS BODILY INJURY

SCHEDULED AUTOSPer person

HIRED AUTOS BODILY INJURY

NON0WNEDAUTOSPer accident

PROPERTY DAMAGE

Per accident

GARAGE LIABILITYAUTO ONLY EA ACCIDENT

ANY AUTO OTHER THANEA ACC

AUTO ONLY AGG

EXCESSIUMBREI LA LIABILITY EACH OCCURRENCE

OCCUR CLAIMS MADEAGGREGATE

DEDUCTIBLE

RETENTIONWC STATU OTH

WORKERS COMPENSATION AND

EMPLOYERS LIABILITY EL EACH ACCIDENT

ANYPROPRIETORPARTNERIEXECUTIVEOFFICERIMEMBER EXCLUDED EL DISEASE EA EMPLOYEE

If yes describe under DISEASE POLICY LIMITE LSPECIAL PROVISIONS below

OTHER

DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES EXCLUSIONSADDED BY ENDORSEMENT SPECIAL PROVISIONS

Governmental Entity Form CG2026LD22318The certificate holder is named as an additional insured on the generalSee Attached Descriptions

ceurlal I nTlnnl o oavs forNonravmentIGRIIfIVMIG1IVLVGR

THE EXPIRATIONSHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

City of Palmetto DATE THEREOF THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN

516 8th AVe W NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT BUT FAILURE TO DO SO SHALL

Palmetto FL 34221 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR

REPRESENTATIVESAUTHORIZED REPRESENTATIVE

ACORD 25 200108 1 of 3 S39930M39921 THOMC tivlcuIVICrVR111Vn1 1

IMPORTANT

If the certificate holder is an ADDITIONAL INSURED the policyies must be endorsed A statementon this certificate does not confer rights to the certificate holder in lieu of such endorsements

If SUBROGATION IS WAIVED subject to the terms and conditions of the policy certain policies mayrequire an endorsement A statement on this certificate does not confer rights to the certificateholder in lieu of such endorsements

DISCLAIMER

The Certificate of Insurance on the reverse side of this form does not constitute a contract betweenthe issuing insurers authorized representative or producer and the certificate holder nor does itaffirmatively or negatively amend extend or alter the coverage afforded by the policies listed thereon

ruRU caauuiuest 2 of 3 539930M39921

DESCRIPTIONS Continued from Page 1

liability policy but only with respect to liability arising out of the

named insureds operations or premises owned by or rented to the named

insured per form CG2026LD22318

AMS 2532001108 3 of 3 S39930M39921

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