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"SPECIAL EVENT APPLICATION REQUEST FOR OFFICIAL USE ONLY {$25.00 Non-Refundable Application Fee Require. ‘Crpentinna erank: ‘ae atest any econ Fe fo Nox Prot Commercial ___Indepondiant tum to: Maps attached _ ABC Pormit Required CCharotesile Parks & Recreation Trt Permit Regul eto | INDEMNITY RELEASE {In making this request, the applicant understands thatthe sponsor will hold harmless and indemnify the City, its officers, employees, and agents against injury, loss or damage occurring as a result ofthis special event. ‘Sponsors of special events held on public property will be required to provide Special Event ability Insurance Jinan amount not less than $1 milion dolar, naming the City of Chariottesvile, ts oficers, officials, employees ‘and agents as an additional insured party to the contract. For addttonal information regarding ths requirement please contact the Charlottesvile Parks & Recreation Department at 970-3260. Sponsor(s) Name: _JaS0A ler adress: 10/3 B A Houis3q pve. spores loorone: SS HE SSE eS seit concn) | oe Contact Adcress: 1013.8 Altavista AVE Choclorresvilleva 22402. Wear sion 30,3017 Contact Telephone: Office( ) ‘Date Application Received By P&R- Home ( Gall (ot) ATES SEZ 5/2007 APPLICANT SIGNATURE DATE paTE APPLICATION suaMiTteD: 5/30/17 EVENT PURPOSE / BRIEF DESCRIPTION: speedy rally in su the lee. ir IDENTIFY EVENT CATEGORY: __ CARNIVAL _,/ DEMONSTRATION ___FAIR __ FESTIVAL. FUNDRAISER HISTORICAL CELEBRATION ___ MARATHON RACEMWALK PARADE ___ OTHER (eserte Other) evENTvenueaLocanion Requesren: Lee Pari UST RAGEAVALK STREET ROUTES, IF APPLICABLE (A clear & egible map showing walk/aun routes also requested “Please attach map to application} SMECT CLOSING REQUESTED, IF SO INCLUDE LOCATIONS ANU ULUSING /OPENING TIME(S): __ ves No LOCATIONS} CLOSING DATE(S) CLOSING/OPENING TIME(S: FROM” anvpm UNTIL: —__anvpm EVENT START DATE/TIME: ‘at aay B/C r= EVENT END DATETIME: ious Shelly Sp ye (WEEKDAY) (DATE) as SvENT SETUP DATETIME INCLUDE WeEKOAy} wet ep — ons EVENT BREAKDOWN DATE/TIME (INCLUDE WEEKDAY} (WEEKDAY), (ATES rine) nerewomeneavestes ves no o1ercovesreo (WEEKDAY) muncosramonus: HI0 _wuradmuneomuscseusee: ves nol DENTIFY TYPE MUSICAL ENTERTAINMENT REQUESTED: __ BAND _DISC-JOCKEY _OTHER SITY UTILITIES NEEDED? YES___NO.s/“ IDENTIFY TYPE UTILITIES NEEDED, IF APPLICABLE: sr saupen revere sconce are rnescunien: vs foo ies beeen OTHER CITY SERVICES REQUESTED ___ YES ._s/ No ease idently the area of services nesced inclucing staf assistance i applicable IDENTIFY EVENT EQUIPMENT & QUANTITY OF EQUIPMENT TO BE PLACED INON REQUESTED VENUE SPACE. #oFBooTHS_— SIZE OF EACH BOOTH # OF CANOPIES (Pop-Up)_—" SIZE OF EACH CANOPY #0 TABLES SIZE OF EACH TABLE __ sorteNts — SIZEOF EACH TENT ____(000.5q ft. & above will quite = Permit from City NDS Dept} # oF STANDS SIZE OF EACH STAND OTHER EQUIPMENT (See Below) (PLEASE DESCRIBE OTHER EQUIPMENT REQUESTED FOR PLACEMENT): Pease not if other” equipment includes the use of a meon bounce and o inflatable carnival ype ides and actives povided ‘bya Sra party vender, proof of insurance bythe venir providing such equfpment wil be required. The rc party vendor shal provide @ cuTentcertfoate of insurance cating at least $1 milion in ganeral lablty and completed operations coverage and Ceticate of workers’ compensation coverage # appleabl, Said insurance shall nam the Cy of Charotesvile (including ts officers, officals, employees and agents) as an adaltiona insured party to the insurance contract. A copy of sid documents ‘must be provided othe Parks & Recreation Administration Otfice by the requested due date specie. ALCONOUC BEVERAGE HYOIVEDINTAS ACT: __ E81 NO er an dsc ccna octDatnine creat esis borane i he uci Pecs we of celts va Describe: HEALTH DEPARTMENT INFORMATION REQUESTED WILL FOOD BE DISTRIBUTED AT THIS EVENT: __ YES NV” NO Uf Yes a Temporary Food Permit will be required by the State Health Department (Thomas Jeferson Health District (TiO) located on Rose Hil Dive (434) 972-6259. Please provide the below information requested by the TubD). | NUMBER OF VENDORS __ CONTACT NAME (tcitferent from Sponsor/Applicant (CONTACT TELEPHONE (citferent eons |S SITE EQUIPPED WITH WATER FAUCETS/FDXTURES: __ YES _s| NO | MEANS OF WASTEWATER DISPOSAL: