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HomeMy WebLinkAboutHold Harmless AgreementHOLD HARMLESS AGREEMENT This AGREEMENT entered in this rn day of IVdAW 20/f, between the CITY OF SEBASTIAN, a Florida Municipal Corporation (hereinafter called "CITY"), and I-JA provides that: 1. The parties shall cooperate in organizing and conducting your scheduled activities for I ,r from AM� to �AMe in the rented l( LYI N•. 2. -Skr dYSU,'n% without the aid and assistance of City personnel, shall organize and administer all activities and events for said rental. 3. AJa S14e l r",ri agrees to use appropriate parking areas as set forth by the City. 4. Afa -kAZOr ilhvi agrees to indemnify, defend and hold CITY harmless from any and all claims of any nature brought by, la 5 w—k OS '"its members, or agents in the course of performing activities under this Agreement, or from any clais by any persons arising from or damages incurred by the CITY from the actions of Ua S /rt(' sir Jinir , its members, or agents whatsoever arising from the exercise of the privileges and obligations set forth hereunder. AGREED to on the date first set forth above. ATTEST: ,' l ^-��Yh/,I anetxe tldi�liains, MMC City -Clerk Approved as to form and legality for Reliance by the City of Sebastian only: JamA D. Stokes City Attorney CITY OF SEBASTIAN A Municipal Corporaton Joe Griffin City Manager Ala S,k)KeY-Stu)M Organization/Company Name A phi t A� CERTIFICATE OF LIABILITY INSURANCE I DAM 03105i2018m THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement($). PRODUCER I CONTACT Katherine Wilson Sebastian Insurance LLC NAME 1013 US Highway l I PHONE F. i. 772-589-1110 INC, No): 772-589-0731 Katle@Sebastanimurance.com Sebastian, FL32956 I ADDRESS: CO INSURER A: AMERICAN STARES INSURANCE COMPANY 19704 INSURED SINK OR SWIM, NARCOTICS ANONYMOUS (INSURERS: CIO DAWN EYERMAN 820INDIAN RIVER DR INSURER C : Sebastian, FL 32958 INSURER D : INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH PCJCIES. UM1TS SHOWN MAY HAVE BEEN REDUCED BY PAID -MAIMS. INSR. LTR ADDL SUER TYPE OF INSURANCE Iu$glkwn POLICY NUMBER POLICY EFF POLICYEXP �MMIoO/YYYYI (MMADORYYYI LIMITS - A COMMERCML GENERAL LIABILRY I UDC-2185139-CGL-18 02/26/2016 i12/26/2019 EACH OCCURRENCE E 1,�'�I OLAMSMAOE OCCUR AMAGETURIENTELI IPREMISESIFsovnence) a S 1�'�I I LED EW (Any one person) S 5,DD0I I PERSONAL S ADV SU.RY S 1'000'000 GGEE AGGREGATE UNIT AA PER GENERAL AGGREGATE $ 2'�'� IHL POLICY gpT LOC PgODU:Ta CONAIOP AGO $ 2'�'� OTHER: E AIITOMOSILELIASIUTY COMIED SINGLE LIMIT E (Ea amltlaml ANYAU1r0 BODLYNEIRY(Perpe=n) E OWNED SCHEDULED AUTOS ONLY AUTOS EOD0.Y INJURY (Per ecdtlpM) O HIRED NONAUTOS E ONLY AUTOS ONLY 05 ON.V leer euitlentl HSREJ�OCCUi IEACH OCCRNCE S EXCESS LWeCLAAISMADE AGGREGATE $ DED RETENTION $ $ I WORKERSCOMPENSATON PER I 01-H ANDEMPLOYERVUASIUTY YINER STATI.TTEANY I PROPRETOR/PARINEP/EIECURVE EL. EACH ACCIDENT C! S OFFlr�RMy NIA 1. NH)N1UlEOT (Myyantletory In NH) EL. DISFA EMPLOYEE E DEECclesofibe under RPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT E I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLE$ (ALORD tet, Atltlelonal Remarks SchAUule, may Oa aeachetl If more spaco Is raquiraa) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Of Sebastian ACCORDANCE WITH THE POLICY PROVISIONS. 1225 Main Street Sebastian, FL 32958 AUTHORIZED REPRESENTATIVE © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD CITY OF SEBASTIAN FACILITY RENTAL PERMIT APPLICATION m. S HOME OF PELICAN ISLAND 1225 Main Street Sebastian, FL 32958 Parks Phone: (772) 228-7054 FAX: (772) 388-8248 mhemandez@cityofsebastian.org office Us o $250 Security Pd: S' I Rental Fee 40113, DFato 1 Initi I Oil 6.8% Tax Total Rental Pd: 3 f 8 ate Initials City Manager Approval: Date Initials City Council Approval: Date (if applicable) Police Hire Verification: (If applicable) Initials Date: 316_hd ❑ Community Center G�/ Yacht Club AJ 11/1�'h1 �0 s�N1,�i721(fJ�7f I77rUZL/) -Gbh SC(,�ts1✓ _ Name of Permittee (permits i only be issued to fit adult) Name of Organization (if applicable) l5a � Physical Addreslt Mailing Addres (if different) 8 /OoeL�jcS ydWnl �C 329Sg To 6C 30_ _ _ . a� U lia ��Id.-xj ))&uy) —)72-7(a(,'3120 �1�wyni� 9rn�r� //747, Clty State Phone E-Mail L I� Reason for Rental — Type of Functiof`Ji U Anticipated Number of Attendees (if more than 75 attendees, police services are required by R-10-15) Request Date Please answer the following yes or no: 1) Are you a resident of Sebastian? 2) Will there be an admission charge or door charge? 3) Will alcoholic beverages be served? If yes, please provide govt. issued ID proof of age '7a - kPd') Time! From / To l/� S 0 Date of Birth Verified by I, Ti /rio. k J` Q s , the undersigned, acknowledge that I am the applicant or authorized agent of the abov6 reTerenced organization, that I am aware of the provisions of the City of Sebastian Codes and Resolutions in respect to this application and use of City facilities for which I have applied and agree to abide by all rules and regulations set out for use of City facilities. I understand that the $250.00 security deposit will be refunded if the building is left clean and undamaged, however, failure to clean the facilities immediately after the use, or causing any damage to the facility will result in forfeiture, in part or full, of the securi deposit. � Si " atyfe of plic nt LnCf SERST,AN HOME OF PELICAN ISLAND 1225 MAIN STREET SEBASTIAN, FLORIDA 32958 TELEPHONE (772) 228-7054 FAX (772) 388-8248 Acknowledgement of Key Receipt "from Organization/Association, acknowledge receipt of 1 set Q�f// the J keys, delivered by the City of Sebastian on this _�2/day of /"/AJU , 2018. These keys are the exclusive property of the City of Sebastian and must be kept under my direct and exclusive control, until they are returned to the City at the end of the rental/usage period. The keys must not be surrendered to anyone, without prior, written approval from the City of Sebastian. I acknowledge that if the set of keys are lost or stolen, I am to notify the City of Sebastian immediately, and I will be responsible for a key -replacement and processing fee in the amount of $100.00. 1 understand that I am not permitted to duplicate the set of keys. I further acknowledge that I am to use these keys only for the purpose listed on the approved City of Sebastian Facility Rental Permit Application, and only for the rental period listed on the Application. o / /A-P/iM4 /A no_ Printed Name And Ti41e Signature CITY OF SEBASTIAN 1179 PARKS & RECREATION RECEIPT Name S I ►1 lc- Uy SW I rn O Cash Date S—�1 S ❑Check# �rtn-F ur�gvin� r-cn-Fac.QS Yc an & 7-011,� Credit I(e.r 3►�►�,F�15 Amount Paid 001001 208001 Sales Tax "� i� 001001 220000 SecurityDeposit "A. 2S b . p p 001501 362100 Taxable Rent 7*`13 •-7r 001501 362150 Non -Taxable Rent 001501 342100 Police Security Services 001501 366150 Brick Pavers 001501 366000 Memorial Benches 001501 369400 Reimbursement Services i, ! otal PaiA37(-qi Initials White - Dept. of Origin - Yellow - Admin. Svcs. - Pink - Applicant