HomeMy WebLinkAbout1540 French Ave (2)CITY OF SANFORD
APPLICATIDN FOR TEM PORARY USE PERM TT
PERM Ir NO. '- `
7—
DATE: 7-0r6Z
T he undersigned herby applies fnr a pear it for the fnlbw ing des=ded w olk :
O w ner. Ft VL-S T F M-e tGtC-A aU i2c'c1 ott o .
Job A ddmass: 1540 e-" N J ikd t=
N ahue of W oxc : 3 O Y F 0 T;eAJ A/-
Se otK-Jer S,k-1,e S
PamelN o:
A pplicant's N am e: V 4 ' T2 CATr6 A -)
A pplicant! s A ddness: 2.0 %4 (
O/LL_VkAJ90
Applicant'sPhone No.: t{O'?- qZZ-` 477 I
vextify thatthe above mb3rn abon is tuie and conectand thatIw illocn ply w ith allapplxable ocdes and orlinances
of th ity of Sanford, FMda. A
pp]icant's S ignatri3B 9QsG95;
o0(5 ll9gq State
License N um ber (Cf applicable) Peon
it Fee: $ t*,
r-
LIMITED POWER OF ATTORNEY
I hereby name and appoint:
R P.c,C, 132-<-r. 'M ki Printed Name of Appointee
FXKs IY.C A '`''iO''s'S 00. Company Name of Appointee
to be my lawful attorney -in -fact to act for me in applying to Seminole CountyGovernmentCommercial/Residential Permitting. for a permit enabling work to be
performed at the location below -described and to sign my name and do all things
necessary to this appointment:
Section
Township
Range
Subdivision
Block
Lot
tSo 5.cva v„,f u L 3L't-r Project Address
Owner of Property
Owner Address
Signed: G /_
eftified contractor signature
Date: _,q-- 1!5--. 02
Certified Contractor: R,**4A, C. r-7
printed name
Contractor License #: p o v 7 X—
State of Florida )
County oKS)Y-
Swom to and subscribed before me this 1r Jay of 01 Au .Zyo_ a by
name of perso cknowledge'd) who is personal) knowntomeorwhohasproduced (identificat on).
Notary Publi
Commission expires:
FORMpower of ettomey/mlmc/121799
pier#ifir t u£ Jil mr ;A't is #ttnve
ISSUED BY
b
KIRBY TENT RENTAL
Division of Kirby Rental Service & Sales
411 Hames Avenue 8711 Phillips Highway
Orlando, FL 32805 Jacksonville, FL 32256
MANUFACTURERS OF THE FINISHED TENT PRODUCT DESCRIBED HEREIN
DATE: Ki,, 4 1 c-. o Z
This is to certify that the materials used in the construction of the 30 -4 `a T-ea,-V-
Q-eo-
have been flame retardant treated (or are inherently non-flammable)
by the Snyder Manufacturing Company
Their registered application concern number F-140-01 is approved and registered by the State Fire Marshal
and the application of said chemicals was done in conformance with the laws of the State of California and the rules and
regulations of the State Fire Marshal.
Flame Retardancy Cannot Be Removed By Washing And
Is Good For The Life Of The Material.
THEIR
Fabric Meets The Requirements Of Specifications
F-14Listed
As NFPA-701 (Large Scale) 0-
01 f REGISTERED
Signed: APPLICATION
TENT
DEPARTMENT CONCERN
NO.
CITY OF SANFORD FIRE DEPARTMENT
FEES FOR SERVICES
PHONE # 407-302-1091 * FAX #: 407-330-5677
DATE: 4o 2
BUSINESS NAME / PROJECT:
ADDRESS:
PHONE NO.-467— LL72- ! Wo FAX NO.:
CONST. INSP. [ ] C / O INSP.:[ ] REINSPECTION [ ] PLANS REVIEW [ ]
F. A. [ ] F.S. [ ] HOOD [ ] PAINT BOOTH [ ] BURN PERMIT [ ]
TENT PERMIT TANK PERMIT [ ] OTHER [ ]
TOTAL FEES: $ e •
00 (PER UNIT SEE BELOW) ]
COMMENTS: l.i) t I r - A 1 - ' jD
Address / Bldg. # / Unit # Square Footage Fees per Bldg / Unit
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Fees must be paid to Sanford Building Department, 300 N. Park Ave., Sanford, FI. 32771 Phone # -407-
330-5656. Proof of Payment must be made to Fire Prevention division before any further services can take
place. I certify that the above is true and correct and that I
will comply with all applicable codes and ordinances
of the Citv of Sanford, Florid \ -11
Sanford Fire Prevention Divisi Applicant's Signature
HIV
Application Pg I of 2
SPECIAL EVENT'APPL1CAT10N/PV#WVE9V
u JUN i ` 2002
DATE APPLICATION RECEIVED
ol
b ")
1) PERMIT APPLICATION NUMBER
ame of Event:
r
acility/(Airs lion Requested: ISO d S
vent Dalc(s): ZQ-QZ _ KL) _7-$ aZ Event (lours: From: .aci AWPM To: 10:6u AMMM
rlup Date(%): C9' Z 0— Setup Hours: From: AMIPM To: AWPM
must include set-up/cleen-up & decoration lime)
limatcd: Participants Spectators
ypc or Organinlion (Check one): Not for Profit d
dciall.D.# ln`Qa s gt0 Tax Exempt#:
Vehicles Vessels (for Boating events only)
For Profit Individual
Tax #: SS #:
o you anticipate this event being heldnextycar7 -Ifts No If so, Date-. Location: ponaorinR
Organixation Name: Sfl >Fr' Oroy - ` at ---{ V1411 V 6t a OiTce Phone: y 07 - Z - SZZ o on tact
Person Responsible for Event/Cho rges: A(.G- S-(-p'r(6 /,/ Email Address: hone: Work #
1: q
67-
q Z2.' y G t l Home q: Fax #: Cell/Pager PH# 467- Zy, - wz-4 ddress: 1\
QO - h?_-,T City (_ VFW State Zip Code 3Z7-75 dditional Contact
Person: Q. LAtAr _ Work #: 07-307- SZZO Email Address: H07- 41 --6388
lease Note: C - City, A - Applicant, O - Other or NA - Non Applicable to All That Apply For Your Event 1'hc Followin
Z Activities/U%es May Require Permits, Fees and /or Additional Documentation F.%F;N'
T ESTAFF DETAILS EQUIPMEN'r ATEVENTSTAFNEEDSarrival/Circus/hair - - 2. Exhibit cstival 4Tishing
Toumamcnt General
Meeting
r,.l'
ararlc 7.
Picnic/Pany 8-
Tournamcnt/Compctilion 9.
Wcdding Reception V
I0.()thcr, Explain
I 0 12.Alcohol
Beverage
Sales
13.Concession Stands 14.
Ficld Preparations 15.
F i reworks/
Pyrot ec h n i es 16. Food/Beverage/Catcring
17.Mcrchandisc Sales I
S.Open to
Public 19.Special Set-ups
20.Sircet, Lane, Sidewalk
Closure 21.Vendors Number of:
22.Waterm- ectric Z3.
Audio/Video/Sound
Equipment 24.lnllatable Devices 25.
Ponable Rcstrooms 26.
Registration Table 27.
Spons Equipment 28.
Stage/Props/Production
29.Tabics & Chairs 30.
Tents/ Banners/Signage
31.Trash Cans/ Dumpster(
s) 32.Vidco Equipment 33.
Mobile Stagc-Timcs:
Sct up _ 34.0ther, Explain Hourly
Rates ner nerson
35.EMS ($21) 36.
Off-Duty Officer ($
21) 37.Evcnt Managcmcni(S25)
38.Firc(S2) ) 39.
Policc(S21) 40.
Public Works(S20)
41.Recreation & Parks(S15)
42.Code Enforcement (SI8)
Take Down: A MAP
ANINOR DIAGRAM
OF TIIE PROPOSED EVENT SITE/LAYOUT/ ROUTE. MUST BE SUBMITTED WITIf THIS APPLICATION"* If you checked any
or the above items, provide a complete description or the event/request on a Special Event Backup street. lease Provide Below a
Detailed Description of Event and all City services requested*
Application Pg 2 of 2
HOLD HARMLESS AGREEMENT: The Contractor, Vendor or User hereby promises and agrees to indemnify and save harmless the City of Sanford, a municipal
corporation, its officers, agents, and employees, from and against any and all liability, claims, damages, demands, expenses, fees, fines, penalties, suits, proceedings,
actions and cost of actions, including attorneys' fees for trial and on appeal of any kind and nature arising or growing out of or in any way connected with the performance
of the Agreement whether by act or omission of the Contractor, Vendor, officers, agents, servants, employees or other or because of or due to the more existence of the
agreement between the parties.
The applicant will supply a "Certificate of Insurance" reflecting minimum coverage of $500,000 per occurrence for bodily injury and property damage. The City of
Sanford as additionally insured which will be noted on the Certificate. The Certificate will indicate that the applicant's insurance policy will not be canceled without
thirty days prior written notice to the City. The undersigned agrees to abide by the regulations governing the said facility and is responsible for charges incurred and must
supply a "Certificate of Insurance" to the Recreation Department no later than five (5) calendar days prior to prograndevent date.
Copyright Law: Licensee assumes all costs arising from the use of patented, trademarked or copyrighted materials, equipment, devices, processes, or dramatic rights used
on or incorporated in the conduct of any event covered under the agreement and licensee agrees to indemnify and hold harmless devices, processes or dramatic rights
furnished or used by licensee in connection with the agreement and will defend the City from any such suit or action, regardless of whether it is groundless or fraudulent.
CERTIFICATION BY APPLICANT: I certify that I have read this application and that all information contained in this application is true and correct. Any
falsehoods or misrepresentations will constitute a criminal violation of the code of the City of Sanford. 1 certify that 1 have received a copy of city code chapter I8a.
I agree to comply with and be bound by any and all applicable provisions of the city code. I understand the event may be cancelled by the Chief of Police or The Fire
Chief should any conditions/stipulations of the permit or city ordinance or state statute be violated. 1 certify that 1 am authorized by the organization named herein to act
as its agent for the herein described activity. 1 also have received the notice informing me of my responsibilities and obligations should I cancel the event.
By filing this application,1, and the organization on whose behalf I make this application, contract and agree that we will jointly and severally indemnify and hold the city
harmless against liability, including court costs and attomeys' fees for trial and on appeal, for any and all claims for_damage to property or injury to, or death of persons
arising out of or resulting from tissuance of the permit or the conduct of the activity or any of its participants.
icensee Signature late
II hereby certify that all the
ma just cause for imm,
kAlkw r
Signature of Applicant:
wined herein is true and
of any permit(s) issued.
Signature
LICENSEE CERTIFICATION
correct to the best of my knowledge. If any portion is found to be Ialse or mtsrepresentea, sucn tact
14 [ 6 Z
Date
Date: (p 1 (4 G 7—
Subscribed and affirmed before me 6 / 114 / L 2- By(Print Applicant Name) m ptc q S:Ta yk--IT,0 A
He/she is personally know to me OR has presented 7 " i o ' 2. Z U As identification and who did take an oath.
type of identification)
EVEUNE E. BENNEIT
l MY COMMISSION S DD 053453
Notary Signature and Seal: ` 7 x CI= My commi EXPIRES: August 28, 2005
The program/ev nt will be terminated s ould licensee cause any violation of Local, State or , .
OFFICE USE ONLY
COPIES OF THIS PERMIT REVIEW BY (CHECK). RECOMMENDING APPROVAL BY INITIAL/DATE.
Engineering & Planning Dept
Parks Department
Public Works Department
Utility Department
Permit O/Approve 0 Deny
Received:
Application Fee:
Special Event Fee
Dat
G l 2 D Z
qw
7LC
By Authorization of
Date
V Code Enforcement Division
Fire Department
Police Department
Risk Management Division
Received:
Clean Up Bond
Certificate of Insurance
Date
CIO
Date_/ 9 -
Date
FOR OFFICE USE ONLY
SERC EVENT"W:ORKSHEET
RECREATION & PARKS DEPARTMENT SUB -TOTAL COST $
Special Event Division of of
Rates of Hours Days Cost
11 Api ication Fee 50.00 X X X =
t/Clean Up Bond 100.00 X / 6 X .— X = 1 )
Event Management 25.00 X X X =
SERC Meeting Date @ 10:00am
City Commission Meeting Date @ 7:00pm
Other: X X X =
Other. X X X =
Additional Comments:
Review and Recommend El Approve El Deny By (Signature & Date)
Facilities & Grounds Division of # of
Rates of Hours Days Cost
Facilities Use Permit X X X =
Electricity 50.00 X X X =
Park/Facility Monitor(s) 15.00 X X X =
Prep/Breakdown Crew 75.00 X X X =
Risers/Stage (4'xg' piece) 50.00 X X— X =
PA Sound w/ Operator 50.00 X X X
Tables 10.00 X X X
Chairs 4.00 X X X
Extra Trash Receptacles 5.00 X X X
Tent (10'x 10'-$75/ 20'x20'-$150) X X X
Other: X X X
Other: X X X
Additional Comments:
Review and Recommend O Approve El Deny By (Signature & Date)
FIRE DEPARTMENT SUB -TOTAL COST $
Fire Marshall Division # of # of
Rates # of Hours Days Cost
Off -duty First Aid/Paramedics $21.00 X X X
Off -duty Fire Personnel $21.00 X X X
Fire Inspection $25.00 X X X
Additional Comments:
Review and —Recommend. 0 Approve Cl Deny By (Signature & Date)
FOR OFFICE USE ONLY
POLICE DEPARTMENT SUB -TOTAL COST $ .
Special Operations Division of of
Rates of Hours Days Cost
Security/Crowd Control 21.00 X X X
Traffic Control 21.00 X X X
Alcohol Control 21.00 X X X
Off -duty Officer 21.00 X X X
Loud Speaker 5.00 X X X
Additional Comments:
Review and Recommend Approve Deny By (Signature & Date)
ENGINEERING & PLANNING DEPARTMENT SUB -TOTAL COST $
Codes/License/Permit Division of of
Rates of Hours Days Cost
Site Layout/Map
Vendor(s) X X
Tents (400sq/R or more) 20.00 X
Assemblies/Parade/Race 56.00 X X
Fireworks/Pyrotechnics 50.00 X X X
Application Fee 10.00 X X X
Street, Lane or Sidewalk Closure 350.00 X X X
Alcohol Beverage 100.00 X X X
Banners)/Signage(s) 10.00 X X X
Camival/Fair 625.00 X X X
Inflatable Devices 10.00 X X X
Amusement/Rides ($150 Plus) 37.50 X X X
Block Party 25.00 X X X
Port -O- let Restroom (s) 150.00 X X X
Code Enforcement Officer (s) 18.00 X X X
Circus —Per D y 200.00 X X X
Other: X X
Comments: Additional permits may be required from other governmental entities hch as water management districts,
state agencies, or federal agencies.
Review and Recommend Approve Deny By (Signature & Date)
UTILITY DEPARTMENT SUB -TOTAL COST $
Support Service Division # of # of
Water/Electric/Gas Locate
Water Meter Deposit
Additional Comments:
Rates # of Hours Days Cost
15.00 X X X = $
450.00 X X X = $
Review and Recommend Approve Deny By (Signature & Date)
FOR OFFICE USE ONLY
PUBLIC WORKS DEPARTMENT SUB -TOTAL COST - $
Streets, Facilities, Stormwater and # of # of
Solid Waste Division Rorer # of Hours Days Cost
Bmincr (Hung/Remove) 121.00 X X X
Trailer Stage (Setup/Breakdown) . 325.00 X X X
Public Works Monitor (S) 20.00 X X X
Vehicles/Equipment 20.00 X X X
Traffic Control - Attachment A X X X
Dumpsters - Attachment A X X X
Street Sweepers - Attachment A X X X
Other: X X X
Other: X X X
Additional Comments:
Review and Recommend O Approve O Deny By (Signature & Date)
FINANCE DEPARTMENT SUB -TOTAL COST $
Risk Management Division
Hold Harrnless Agreement must be signed on application. The items checked below must appear on the Certificate of
InsurancP, wiWw minimum of $1,000 000 General Liability and must name the City of Sa ford as Additional Insured:
Gcvta i Ct ad;lr r S',o v occcva crry by a 6a
Automobile Liability Insurance minimum of $1,000,000 Providing coverage on a per occurrence basis are required in the
amount of the General Liability requirement if automobiles are used as part of the event.
Product Liability Insurance is required i*_ 3a4 tF PWV /;c, Flvc ;-'t'0`i.... Each vendor (an entity in the
business of making a profit) must provide proof of a minimum of $1,000,000 Products Liability Insurance, fc.v occ4vv en
Liquor Liability Insurance with a minimum limit of $1,000,000 is required if there -is the sale or consumption of alcoholic
beverages at the event.
Worker's Compensation Insurance, in accordance with Florida State Statutes, will be required and afford protection to, any
City of Sanford off duty employees hired by the event holder/sponsor to work the event.
Proof of Insurance must be provided for all automobiles and/or boats to be used in event.
Additional Comments:
N
O Approve O Deny By (Signature & Date)
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6-19- 2002 2 : 20PM 1= ROM FIRST AMER I CAN CO. 407 422 4676
Sent by: Amo-scan Pi,omotionai Products 2567600154; 08/19/02. 2:11PM;jgEpA 0676;Page 2/3
DIWA'YMN INSURANCE BROKERS. INC
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CERTIFICATE OF INSURANCE NO. 294339
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Demawe &isulg out jWft =Uftuoa a use o(b wnd Ratan Ftr®iss. USED PRV CIPALLY FOR THE RETAIL
SALE of D.O.T. Clan "C" Fatiwoolts and velaW item.
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Wx1v, F`L 32804 Winter Park FL 3M9 Safe
Hmi: of Sanilzoie :Rataoo U.S.A. Drvelop aW Corp. 1100
E. Elm St. Sanford T*ow SQ. city ar Sanford SadwL
1:132773 1340 S. Fmob Ave. 300 Mob Pads Ave. SuWbcd,
FL 32771 P.O. bu 1795 Saofan3.
FL 32771 i
OC ATM OF IIGU ED RETAIL
PR:PMM Sauford
Towne Square Sanfot+
4, Florida 32771 PEWDOFCOVERAIGE ]
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INSUR/NCE BROIC1' S, INC. 02-
DATE
OF ]VIM STR>KCER. PitE3ID1..
6— V: —2002 2 : 22PM FRG-M FIRST AMER I CAN CO. 407 422 4676
Sent by:,r.,nerican Promotional Prociucts 2567600154; 00)19/02 2:11P1A;J&jbL,_#976;Fog* 3/3
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DRXffON INSURANCE BROKERS, INCU.
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CERTIFICATE OF INSURANCE NO. 298801
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32773 1540 S. Fmw;b Avc. P.O. Boat 1748 Sa Fwi.
FL 32771 Seaford,1132771 In *a
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