Special Event Permit - The City of Covington

Name and Date of Event:SECTION 33.1 ATTENDANCE AND LOCATIONS OF EVENTExpected total attendance for this event?LOCATION OF EVENT: Check below all that applyWhat areas are to be utilized by the Special Event?STREETSPARKS *SIDEWALKSPARKING LOTSOTHER PRIVATEPROPERTYOTHER PUBLICPROPERTYSTREET CLOSURESPARKINGRESTRICTIONSCheck all that applyList by nameList by name*Before proceeding see Section 3.1 aExact areaList by nameAddressList by nameName the streets and boundaries:Name affected and adjacent streets and describe boundaries:List impacted routeAFFECTS TANK BUSROUTES*The information on this page must accompany notifications to surrounding residents and businesses.3.2 MAP OF AREA CLEARLY SHOWING WHERE EVENT WILL OCCUR AND A DETAILED SITE PLANMUST BE SUBMITTED WITH THIS APPLICATION.3.3 ALCOHOLSERVICE/SALESALCOHOL SERVED? Yes ALCOHOL SOLD? *Yes No *Before proceeding see Section 2.2 No All Applicable State and City Temporary ABC Licensed Must Be Obtained Along With Permission from theCity to Serve or Sell Alcoholic BeveragesSection 4City Endorsed or SponsoredCITY ENDORSED OR CO-SPONSORED EVENT?* A City-sponsored event is one that the City is either funding or supplying in-kind services to the event.YesNoSpecial Events Coordinator Signature:

Name and Date of Event:SECTION 5DEPARTMENT5.1 PoliceCOST ESTIMATE FOR SPECIAL EVENTDIRECTOR ORCONTACT PERSON(INITIAL APPROVAL OR STATEREASON FOR DISAPPROVAL)DATEREC’DBY DEPTDATEAPPROVEDNO. OFSTAFFREQUIREDCOSTPER UNITTOTALCOSTESTIMATECHIEF RUSSODATEDATE$APPROVED APPROVED WITH CONDITIONS (Attach conditions) DATEDENIED (Attach reason)DATEAdditional Non-Staff Costs (describe with cost estimate): $Applicant contacted and accepted costs: Y/NDEPARTMENT TOTAL:$5.2 FireCHIEF NORRISDATEDATE$APPROVED APPROVED WITH CONDITIONS (Attach conditions) DATEDENIED (Attach reason)DATEAdditional Non-Staff Costs (describe with cost estimate):$Applicant contacted and accepted costs: Y/NDEPARTMENT TOTAL:$5.3 Public WorksTOM LOGANDATEDATE$APPROVED APPROVED WITH CONDITIONS (Attach conditions) DATEDENIED (Attach reason)Additional Non-Staff Costs (describe with cost estimate):$Applicant contacted and accepted costs: Y/NDEPARTMENT TOTAL:$5.4 Parks & RecreationNATALIE GARDNERAPPROVED APPROVED WITH CONDITIONS (Attach conditions) DATEDENIED (Attach reason)DATEAdditional Non-Staff Costs (describe with cost estimate):$Applicant contacted and accepted costs: Y/NDEPARTMENT TOTAL:$TOTAL CITY COSTS ESTIMATED: Department totals to be computed by Special Events Coordinator.THIS AMOUNT IS SUBJECT TO CHANGE DUE TO NEEDS OF EVENT THAT COULD NOT BE ACCURATELY ESTIMATED INADVANCE. ANY AMOUNTS IN ADDITION TO ORIGINAL ESTIMATE REMAIN THE RESPONSIBILITY OF THE APPLICANT. $DATESEP Coordinator Initials:DATEDATEDate Initial Review Sent Back to Applicant:$

Name and Date of Event:SECTION 66.1 INSURANCE HOLD HARMLESS AND INDEMNIFICATION AGREEMENT: All events will require the following HoldHarmless and Indemnification Agreement to be signed:The applicant/sponsor of the event agrees that for in consideration of the use of public facilities, right-of-ways and citystaff oversight and personnel involvement, the applicant/sponsor of the event shall indemnify and hold harmless the Cityof Covington, its city employees, and elected officials from all claims for damages and liability arising from the issuanceof the special event permit and any occurrence or incident at or in any way related to the event.For Organization’s Legally Authorized Representative:______________________________________________________________AUTHORIZED SIGNATURE & TITLE____________________________DATEVERIFIED: (Certificate of Liabilty provided, showing City of Covington as named insured)Signature and date verified:Section 77.1 NOTIFICATIONS: all adjacent properties and businesses must be notified in writing by theorganizer no less than 5 business days in advance of the event unless determined otherwise during review.ENTITIES TO BE NOTIFIED: Details/Comments:Adjacent properties (list below) 7.1 aAdjacent businesses (list below) 7.1 bNeighborhood Associations 7.1 c(list all affected)TANK BusOther public entities or agenciesaffected/to be notified:7.1 a 7.1 bAdjacent Properties (list address of each to be notified)Adjacent Businesses (list address of each to be notified)Please attach additional information if more room is needed7.2Estimated Cost of Notification Mailings: No. of pieces: Cost per piece:TOTAL COST:$Notification Date:_____________________________________ (please attach example of notice andmailing list)

Name and Date of Event:SECTION 88.1 SPECIAL EVENTS INTERNAL ROUTING LOG DATE NOTESApplication Received:Sent for Department Review:PoliceFireDepartment of Public ImprovementsParks & RecreationOmbudsman/Neighborhood ServicesReceived back from:PoliceFireDepartment of Public ImprovementsParks & RecreationOmbudsman/Neighborhood ServicesReview Completed by City Manager:8.2Review Requires SEP Committee MeetingY/N and date ofscheduled meetingCost Estimate(s) - Section 5 cost estimateSection 6 cost estimateTOTAL COST ESTIMATEDate Sent to Applicant:Application Rec'd back from Applicant for Final Approval:Approved/DisapprovedApplicant Notified:Notification to Adjacent Properties Sent:Notification to TANK:Notification to other Public Entities:List:1)2)3)8.3CITY MANAGER REVIEW: APPROVED APPROVED WITH8.4CITY MANAGER SIGNATURE AND DATE:CONDITIONS (see attached)DENIEDDate