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COMMUNITY DEVELOPMENT DEPARTMENT Submittal oate: "'
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SPECIAL EVENT PERMIT APPLICATION
Any Village resident, or any Village business hoiding a current Village business tax rec ipt pursuant fo Chapter 70, Article II, is eligible
to apply for and obtain a special event permit pursuant to Sec. 78-561. Any such resident or business that desires to conduct any
type of special event within the Village must obtain a permit from the Village in order that the Village may adequately provide for
the potential impacts created by the proposed event. A maximum of four (4) such permits shall be allowed per address or per
business in any single calendar year. A special event that includes multiple addresses, for example within a shopping center, shall
count as one event for each address captured by the special event permit.
"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 flow of vehicular or pedestrian traffic, which is
likely to create noise in excess of that typically associated with the areas upon which the vent is to occur, or which is likely
to preempt or restrict use of property typicafly accessible by the general public. Examples of special events include, but are
not limited to block parties, parades, races or walks, 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
property shall be exempt from the provisions of this section.
Written application must be submitted to the Village Community Development Department at least forty five (45) days prior to the
date for which the special event is proposed; which application shall contain the following information:
DATE OF SALE/EVENT: �f� / 31 I I� HOURS: FROM: k� �h`I T0: �� � Y�
TYPE OF EVENT: ��4 �— f EST�� A�--
LOCATION OF EVENT: �AS'� �'(�f K� � LoT � F �IFLS i�1� t'�l 5 l CH (�RC �•�{ T�C,���E S � i�
PROPERTY OWNER: ��C�S ��Aw i�S'(" � tiuk�C rl v F T�_�i��F S i Fl (Attach written consent of property owner of record.)
Print Name
CONTACT INFORMATION:
SPONSOR or PERSON{S) RESPONSIBLE FOR EVENT: m��1��K .�h'�YY�� S�f}11�-�- �IC(-� (1RD Sa�J
EMAIL: �r�t� �PqueS� aS C �tu�'Y.�t . r�e.�'
MAILING ADDRE55: ��r�3 Teques�2 ����� PHONE NO.:C 5 � �� ��� � 4 �� 7
�e4uPS��n } F�. 33�Fb`� FAXNO.� ��r� 7�b -- 4�'7�,
PROIECTED NUMBER OF ATTENDEES: c COUNCII APPRQVAL REQUIRED: (�/j'PES ( )NO
• Any proposed special event whose attendance is contemplated to exceed 200 people in total shall require final approval by
the Village Council which, after considering the recommendations of the Cornmunity Development Director, the Police
Chief and the Village Manager, may approve the application, deny the application in whole or in part; or approve the
application with conditions.
IS ALCOHOL BEING SERVED? ( )YES (n)NO
• The service of alcoholic beverages at any special event shall require the issuance of the appropriate state alcoholic
beverage permit, a copy of which 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 within which alcoholic
beverages may be consumed and/or the use of security or off-duty law enforcement personr�el at the special event.
• It is the applicant's responsibility to monitor for and prevent excessive as well as underage consumption of alcoholic
beverages at all times.
Page 1 of 2
• By submitting a complete application, the applicant expressly agrees that it shall indemnify, defend and hold the Village
harmless from any and all damage to any real or personal property, and from any and all injury or death suffered by any
person directly or indirectly related to the consumption of alcoholic beverages in conjunction with the special event.
NON-PROFIT 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, either regularly or temporarily, when the applicant signs an
affidavit that the applicant operates without private profit, for a civic, public, charitable, youth, service, educational,
literary, fraternal, or religious purpose.
o A person making application under this section must comply with all rules and procedures for the granting of special event
permits as set forth in this section. All persons operating under a non-profit permit shall operate their non-profit enterprise
in compliance with this section and all other rules and regulations of the Village.
THE FOLLOWING ITEMS ARE REQUIRED TO BE SUBMITTED AT TIME OF APPLICATION:
• Proof of insurance in amounts acceptable to the Village for the type of event. The Village shall be narned as an additional
insured on all liability insurance.
e Expected traffic, fire-rescue, and utilities impact, if any, and proposed mitigation plans.
o 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 required if the event is held on any Vi�lage property.
• Site Plan required with each application accompanied with drawing indicating layout for event.
� All sale sites shall be left in a clean and orderly manner upon completion of sale.
o Should the sale/event include the use of one or more tents, a$35.00 Fire Inspection Fee, due at time of application, and a
certificate of flame resistance is required for each tent. Inspection to be done on the first day of event.
SPECIAL EVENT FEES:
• Under 200 attendees: $40.00
� Over 200 attendees: $100.00
SIGNATURE OFAPPLICANT: '1��RI� �Aj�'l£ S �-%� ���� � DATE: A � � / k�
Print Name Sig ture
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RECOMMENO FQR APPROVAL
COMMUNITY DEV. DIRECTOR:� 1 DATE: __?��
BUILDING DIREC 0 � DATE:
POLICE CHIEF: �'� c /�` �" 9 ' ��
DATE:
FIRE CHIEF: � DATE:
PARKS/R REATI /V DATE:
APPROVED BY
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�° .�"�--� / . .
.VILLAGE MANAGER: �DATE: ��� / � ' ��f'' '
Approval/Review Notes:
Page 2 of 2
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A'�`� � CERTiFtCATE OF LIABILITY tNSURANCE QRTEiMNtlDDlYYYY►
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THIS CERTtFiCATE IS tSSUED AS A MAT7ER QF 1NFQRMATION ONLY AND GONfERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THlS
CERTIPICATE DOES NOT AFPIRMATIVELY OR NEGATIVEIX AMEND, EXTEND OR AI.TER THE COVERAGE AFFORDED BY THE POLICIES
SELDW. THIS CERTIFICATE QF INSURANCE DOES NOT CONS?ITUTE A CONTRACT BETWEEN THH ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFlCATE HOLdER.
IMPORTQNT: If the certificate hoider is an ADDITtQNAL INSURED, the policy(Fes) must be e�dorsed. If 3UBROGAT(ON IS WAIVED, subJect to
the terms and conditians of the pollcy, certain policies may require an endorsement. A statement on this certiftcate does not confer rights to the
certificate halder in lieu of such endorsement(s).
PRODUCER �fl
NAMB:
Marah & MeLeanan Agency LLC Co.- Florit���,.,, t,;; ;._,..' I° pHONE FAX
9650 NW 91st Street (305} 591-0090 q� Mo;(766) 662-6229
Suite 100 E-MA��
Midmi k"L 33178 ',j i' ;i �? ,/{�;�, g �
1NSURER S AFFORDINO COVEttA6E NAIC �
IN3URERA:Phi18de1 hid Indemnft IRS CO. 18058
INSURED , , �.,; cS5611,,7,6�44a7 �µsURERB:
First BaptiaC Church of Tequesta, Inc.
INSURER C :
P. O. BOX 371$ INSURERD:
T�qtteet8 BL 33469 INSURERE:
INSURER P :
COVERAGES CERTIFICATE Nt1M$ER: Cert In 53309 REVISfON NUMBER:
THIS IS TO CERTIFY 7HRT THE POLICIES QF WSURANCE Lf$T�D BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABQVE FOR TME POLiCY PERIOD
INDICATED. NOTVMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT QR OTHER DOCUMENT 1MTH RESPECT TO WHICH TH1S
CERTtFICATE MAY BE ISSUED QR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POWCIES DESCRIBED HEREIN IS SUBJEGT TO AEL THE TERMS,
EXCLUStONS AND C4NDITIdNS Of SUCH POUCIES. UMlTS SH01MN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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LTR P4lICY NUM6ER MM/pplYYYY MhND
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MED EXP (An aie erson S 15, 000
PERSONAL8ADVINJURY S 1,000,000
GEN'LAGGREGATELIMITAPPLIESPER: GENERALAGGREGATE S 2,000,006
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WORKERS COMPEMSATION
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OE3CRIPTtON OF OPERAi'IONS ! 40CATION$ i VEHICLES (ACORD 141, Addidona{ Remarks Sehetlute, may be attached H more space is required�
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Certificate holder, as Designated Organiaation, ia an Additional Snaured as reageata Geaeral
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CERTIFIGATE HOI.DER CANCELLATION
SHOULD ANY OF 7HE A64VE DESCRIBED POLICtES BE CANCELLED BEFORE
THE EXPIRATION DATE 7HEREOF, NOTlCE WILI. BE QELIVERED IN
ACCORDANCE WtTH THE POLICY PROVISIONS.
Village of requeata
345 Tequeata DrivB, AUTHOftfZEDREPRESEN7ATIVE
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OO 1988-2014 ACORD CORPORATION. AI! rights reserued.
AG�RD 25 (2Q14101) The ACORd name and logo are registered marks of ACORO
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-" ; VtLLAGE OF TEQUESTA
BUILDING DEPARTMENT
� � 345 Tequesta Dr.
� � Tequesta, Florida 33469-0273
� y (561 } 768-Q450 FAX (561) 768-0698
INVUICE
September 07, 2016
Permit #: SEP16-000014
Address: 423 TEQUESTA DRiVE
Contractor: FIRST SOUTHERN BAPTIST CHURCH
PO BOX 3718
JUPITER FL 33469 1Q11
FEES:
Description Total Cost
Over 200 Attendees 100.00
To#ai Permit Amount: 100.00
Total Amount Paid: 0.00
Remaining Balance: 10Q.00
Maureen McGuinniss
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