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�; - VILLAGE OF 7EQUESTA _
• COMMUNITY DEVEIOPMENT DEPARTMENT PERMIT NO: S F' --'
Submittal Date:
,, VILLAGE OF 7EQUESI'A 345 Tequesta Dr. �epositan,ount: _._
a �EP 0 S 2L�;5 Tequesta, Florida 33469 .� �
(561� 768-0450 Fax (561) 768-0698 '; , � n ;, ;
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BUILCiNG �7EPr1"i"' � � � + pECIAL EVENT PERMIT APPLICATION
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Any Village resident, or any Village business holding a current Villaoe business tax receipt pursuant to Chap[er 70, Article II, is eligible
to apply for and obtain a special event permit pursuant [o Sec. 78-561. Any such resident or business that desires to conduct any
type of speciai event evithin the Village must obtain a permit from the Village in order that the Viltage may adequately provide for
the potential impacts created by the proposed event. A maximum of four (4) such perrnits shall be allorved per address or per
business in any single calendar year.
"Special Event" is any outdoor activity, gathering or group of persons, vehicles or both, organized and having a common
purpose, upon public or private property, which is likely to inhibit the usual floev oF vehicular or pedestrian traffic, which is
likely to create noise in excess of that typically associated ��rith the areas upon �vhich the vent is to occur, or which is likely
to preempt or restrict use of property typically accessible by the general public. Ex�mples of special events include, but are
not limited to btock parties, parades, races or evalks, grand opening events, charity fundraisers, and other similar events not
specifically permitted by the Village's zoning ordinance. Special Events that are sponsored by the village and held on village
proper[y shalf be exempt from the provisions of this section.
Written application must be �Fibmitted t� the Village Community Development Department at least forty five (45) days prior to the
date for vrhich the special event is proposed; �vhich application shall contain the following information:
DATE OF SAIE/EVENT: �Rv �av 7_� , '�_c� � ti � HOURS: FROM: �a - :.�� 0. �� T0: \v : :,.a �``
TYPEOFEVENT: � � �cv.;�>. ����.����c� �� �s,-ti �� �tic C: ��3 ��
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LOCATION OF EVENT: w - �� :L� c �3.t . 'T�� � `i. �A� C�oo�
PROPERTY OWNER: c r� •� �=— rc (Attach Nrritten consent of property oo�mer of record.)
a Print Name
CONTACT INFORMATION:
SPONSOR or PERSON(S) RESPONSIBLE FOR EVENT: \'JSi\ �„� \ ��c �v•A �.1. C�.o. NN Q. �,
��'vG �a..�,M'"� �rna�^.�:.-.�.>
EMAII: �`a..�.,���
MAILINGnODRE55:� pZi�-�t- �,4� _ PNONE NO.: ��1�\ �=,�'��. b �`�1 �
�.?-??�s.�S��r��1Zi �k c !� � L. '����2� FAX NO.:�
PROJECTED MUMBER OF ATTENDEES: ��,�� CQUNCIL APPROVAI REQUIRED: ( i')YES ( )NO
• Any proposecl special event �vhose attendance is contemplated to exceecl 200 people in total shall require final approval by
the Village Council tivhich, after considering the recommenclations of the Community Development Oirector, the Police
ChieP and the Village Manager, may approve the application, deny the application in 4vhole or in part; or approve the
application with conditions.
IS ALCOHOL BEING SERVED? ( )YES ( )NO
• The service of alcoholic beverages at any special event shall require the issuance of the appropriate state alcoholic
beverage permit, a copy oF�vhich must be provided to the village in conjunction with the special event permit application.
• The Village may require the use of physical barriers to deFine and contain the outdoor area �vithin aihich alcoholic
beverages may be consumed and/or the use of security or off-duty laµ� enforcement personnel at the special event.
• It is the applicant's responsibility to monitor for and prevent excessive as �vell as underage consumption of alcoholic
beverages at all times_
Pa3e 7 ot 2
• By submitting a complete application, the applicant expressly agrees that it shall fndemnify, defend and hold the Viliage
harmless frorn any and aft damage to any real or personal property, and from any and ail injury or death suffered by any
person directly or indirectly related to the consumption of alcoholic beverages in conjunction with the special event.
NON ENTERPRISES:
• The Village may issue non-profit permits to any person or organization for the conduct or operation of occasional sales
and/or fundraising projects held by non-profit enterprises, eiiher regularly or temporarily, when the appiicant signs an
affidavlt that the appiicant operates wlthout private proflt for a civic, public, charitable, youth, service, educational,
literary, fraternat, or religious purpose.
• A person making application under this section must comply with all rules and procedures for the granting af spetial event
permits as set forth in this section. All persons operating under a non-profit permit shatl operate their non-profit enterprise
in compliance with this section and all other rules and regulattons of the Village.
THE FOLLOWING ITEMS ARE REQUIRED TO BE SUBMITTE� AT TIME Of APPLICATION:
�• Proof of insurance in amounts acceptabie to the Vi{lage for ihe type of event. The Vlfage shall be named as an additional
insured on all liability iruurance.
• Expected traffic, fire-rescue, and utilities impact, if any, and proposed mitigation plans. ,
• Copy oF all required state and county permits if event will be held on or utilize state and/or county-controlled property.
• A refundable deposit Is requlred if the event is held on any Village property.
• SitePlan required tivith each application accompanied with drawing indicating layout for event.
• All sale sltes shall be left in a clean and orderly manner upon completlon ofsale.
• Should the sale/event inclade the use of one or more tents, a$35.00 Fire Inspection Fee, due at time of application, and a
teriificate of flame resistance is required for each tent. Inspection to be done on the first day of event.
t � �
SIGNATURE OF APPLICANT: � • ��:��. � \ C _ �- DATE: � "� � '
Arint Name Signature
�*�Y#�Ftk*##�#*#:R#k�#######�t##tt####+F#�k##t##+Y#ii#�Y�#�11##3####�i+kki�t�R#;*��#Y�ti*ittt�###%�i#+t�##i
RECOMMEND FOR APPRO Al: � ,.
POLICE CHIEF: / � QATE: �� � �� '
, _ a.--� C % i
FIRE CHIEF: . ,�.'-'`- ' DATE: � >>t'
/ . �
PARKS/RE�71�N: DA7E:
COMMUNITY DEV. OIRECTOR:_� .( � ��i�.�.G��%�- � _ DATE: �
APPROVED BY:
__ _._
_ .,,,.,,. .
VILLAGE MANAGER: - � ` DATE: R ' ' '
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Page 2 of 2
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''`��!�� CERTIFICATE OF LIABiLITY IN$URANCE � sia�a�o s
THIS CER7'lRCA'M'E IS ISStl�D AS A MATTER OF INFOBWI7'IOM 11D1LY AND CbNFERS NO iiIQHTS UPON THE CER7IFlCA'IE HCLDER 'iHIS
CERTIFlCAT& QOES NOT AFFlRMATNELY OR NEf�AZI1lE1.Y AA�ffND, EXTEi11D OR A!'I�R Ti�E GOVERAQE AFFOFi�D SY 7F� POI.ICIE&
eE►.ow n�s �Ftcnr� oF �r�s�cE aa�s t�o�r coNSrrrut� a co��r e�rw�EH n�e �sst�Na i��(s�, AtrrHaav.��
REPRESENTATiVE OR PRODUCER, MIQ'fHE CER7'iFlGATE H�LDER
xwPOa�ra�r: � s�, ce�nca� �►aaa � an aournoaa� iHSUt� me aak�) muec bs enac�t. � susaoan�non� �s wav�. Sun� �o
the sstms and condiHons of the poQoY, certain pollcias msy nqutre an endorasm�ni A a�aten+errt oR th�a ceetiflc�te� does r�ot eottter dghts tio iRe
aer![tteete hoider 1n Ilau of aueh aeMorsarrer�t(s
��� . 1�fax�gareE M. Mapers
6'fiAR iasuranc� - Fort ltayae Office �ONE ,(260)�67-5689 �a6o��z-ss9�
2130 8a�t D�tpoat Road .marqaret.mngtr�s@stertiaamcia7..�
APTOADINCi OOtIFFAOE NAIC f
Fort Na e I11 468�5 n�q tional Casnalt a 12991
iNauaEO g��,t�oa�ride I.i.fe Iasurence Co. 66869
Road Ruaners Club of amer�.��aais and =ts
Hember Clubs aau�eu:
isai i... Highivap, Su3te 140 �� .
lArlingtoa vA aZ209
COVERA�ES CERTIFlCATE NUMBER:�015 -$il[ g. I. REVISlON MUMHER:
nais �s To aERnFV n�ar �� potlClES oF INSURANCE IISTED 9ELOW HaVE BEEN lSSUED TO THE lNSiIRED NAMED ABOVE FOR 7NE POLlCY PERtOD
INDICA7ED. IVO'f1MTHSTANDING ANY REQWREMENT, 7ERM QR C08lDITlON OF ANY GONTRAC7 OR OTHER dOCUMEk1T WITH RESPECT TO WNICF! 'fHIS
CERTIRCATE MAY 6E ISSlIED OR MAY PERTAfN, TFlE lNSURANCE AFFORDED BY THE POLCIES DE8CRIBED HEREIN IS SUHJECT 7'O Alt THE tERAAS,
EXCLUStONB ANO COAtDl7i0MS OF SUCH pOLICtES. LIMiTS SNdY1M1 MAY HAVE BEfN REDUCED BY AAID CI.AIMS.
TvaeaFn�aaHCe n u uwars
S c�u�u�aanc. asuirRa�. wswurv eacH occuw��ce s 1.000, 000
A GUHINS�MDE ❑S t�CCUR S 500�000
7C tw�d Ltab;l;t4 t� xn000000a��iaaoo ax/3i/aoxa �a/33/a0=s eeEOar� or„ s 5,000
9.���� at,aoo,000 �a,oi ,w �a:ox ���,,,�,�, 1,000,000
c�ar�noa:�onws�wurrnaaucso�: caEt�tna.�oavE s Un1lai�ed
x POLtCYa,� � LOC Ebna� i xo]�stsEion PRODUCf8-COMR/0PH(30 i 1
pTy� aggregato ;S,0oo,000 AGUSendMolsetatlun S 500,006
M►TQ1HQ61LE IJA9IUTY �� E 1� 000 � �00
� rwn• wurp �II.Y QtRktY 4�rDe� S
nur� n�ur�os�� �ueooaa00049assoo ia�ai/xoia u1�li�ois eoon.rY�,fURVIQar�oota.nU s
X Fu�p�$ z�°" �D ia:oi �w a2:at at� s
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UAIBRELLAUAB oCCtHx OfxURAENCE
dcceas uas ' cwe�ts� naa�on� s
oEO s
WOAKERSCC�N8Ai1pN
AND �IIPLOYEF{8' IdAHIIITY
At�l'/ PROPRIETORlAAATNER7E%ECU7NE Y/H f..i_ EACH ACGIDENT S
orF�cffwn� �ca.u�r � N/a
l� ea.u�ws�-En��o s
oESt`.HIF+'�iroli oF�oPEIinTIONS bebw Fa. u�FASE-pouCr uhrti s
8 B:cess e[saiaai � nooia�ut arxa0000a66seLOO xs�ssiauia izfai/aois �co.eann.ae.i $10,000
(¢250 8adnatibie/eia3m) ia.oi u� ia:oi ax �naev.�e�ess 31,800
DESCFi1PilON4FOPERA7tONS/LOCAT10N5/VENICLES (ACOqQ707,Add16onalRemeeks8ehedub,may6aNtaeh�anmarespawisrequxea)
CSRTZ!'ICAT� HOLDSR IS lIA1�SD AS 1� ADDI�201tAL I�SU�SD A8 R86P8GT8 T88YA IBTSRSST S� TSE OPE[tATiObiB 06' T9E
N�iED TNSIIIt�►. DATB OF BVBNT(S): lil26/15 Rua 4 tLe Pios Theaksgivfng Day 4 Mile Raoe IIiSVR6D
CLtiB/EVBNT �ER: Palm Beach aoadrunn�rs, 8tt'nc Diaaae I�avado, 14341 8velpn Drivo, Pa]m Heach
(;ardeas, [�L 33410
CEFCClFICATE HOL.DER CAWCEl.LA710N
SHOULD ANY OF THH AHOYE DESC818ED POLICIg8 BE CANCELLED BEPORE
11/Z6/15 Vi118g9 of Tsques�a 'M� C%P�RI►T�CN DATE THEt�OF, NOTICE WILL BE OEWaiED fN
Att' a: Special Events ACCOA�AI�ECE Wi7H TFtE POUCY Pi10YISlONS.
345 �'eguosta Drive
1'a�teat�t, 8L 33469 �unwe►uowereas�rtas�vE
3ohn LefeVer/MMA �"�'`'G�'��'�''T'"'"""
� 1888-2014 ACORD COFlPORATlOPt. Ail Hgfris resl�rved.
ACORD 26 (2D#A/rli) The ACORD name and togo are teg€stered marks � ACORD
IN�125 rmtet�t�
, O000ffaG 01�39i13
Consumer's Certificate of Exemption R �,;;
��� = is9ued Pursuant to Chapter 212 Florida Statuies
� RhYE{�IUE •
8S-8qi3958606C-3 12l31/20i2 12/31/2017 5Q1(�){�)(�i��A1V1�lT�(�N
f�tiflCate IVu»ib�er E#fective Date ' - �cpiration Date • . .'. _ �xbjn�i�rn
This certtfles that _ � � . - , C �� T- : .
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. _ . —,_ _ : � .1��•V: .
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PaLM BEACM ROApRUNNERS !NC ';�ae'� :-'a�q: _i -i,�•'ca - � �: -
401 N PIAGLER DR �• " �*_'• ""�°'t'-:• - , , . ._ _ i. _
�; �`� � ;,.:_:=...I�. .._�:;,_� � . _
WEST PALM HEACH FL 3 340 1-4305 ' ••:�;::� _ "' �:='°� .-••: _'S==
'exi� T}��jF(i•s, . . •a`.fu'`� L .:
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Is exempt fr+om ihe paymerrt of Flarida sales and use tax an reai property rented, transient rentat jii+op$ttyr tangibte
personat property purchased or reMed. or servlces purchasad.
lmpoetant lnformation for Exempt Organi2ations �, �°�;;
., .
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OF REYENUE
1. Yau must provide all vendors and supptiers with an exemption certfficata before making tax-exempt parchases.
See Ru1e 12A 1 A3S, Florida Administsative CCrle ('F.A.C.). -
2. Yaur Cons'umer� Ce�cate of Exemption is to be used solsly by your otganixatian for your organir.at�on's
custam�iy nanprofit activities. -
S. Purchases made by an individuai on behalf of the orgaMzation are taxable, even if the ind'nridual wifl be
relmbut�sed by the organrLation.
4. This exemptton applies an�y to purchases your organizatton makes. 7'he sale or lease to athers af tangible
personal property, sleeping accomrr�adations, or other real praperty is taxabls. Your organization musi repister,
and cflllec# and remlt sales and use tax on such taxabta transacUons. {Vote: Chunchas are exempt from this
requlreme�t except.when they are the 4+e�ssor of real properry (Rule i2A 1 A70, F.A.C.)_
5. R is a criminal o�fense to fraudulent{y present this cetttficate to evade the paymsnt af sales tax. Under �o
ciraumstanc� shoutd thls certlficate be used #ar the personaf l�enefit of any indivldual. Vlolatprs will be liat�le for
payment of the sales tax plus a penaFfy af 204% of the tax, and may be subject to aanviction of a thlrcl-dagres
felarry. Any violation wili require the revocatiaa of #his certiffcate.
S. if you haye questians regarding your exemp#ion certlt➢cate, ptease contact the Ex�nption llnit of Accac�nt
Management at 800-352-3B71. From the availabls optfons, select "Regisfrafion of Taxes," ttien "Registration
Information " artd �rnaliy "�xemption Cefificates and PlonprofiE Entities." The mailing addc�ess is PO Box 6480,
Tallahassee, FL S23'14-6480.