TEMPORARY USE PERMIT APPLICATION
BARSTOW Permit No. BTUP-—_--
Application Date:
NON-REFUNDABLE FEE: $94 / $42 (Non-Profit) + Inspection Fee APPLICATION MUST BE SUBMITTED A MINIMUM OF TWENTY (20) DAYS PRIOR TO THE EVENT
APPLICANT INFORMATION
TELEPHONE NUMBER
ORGANIZATION / APPLICANT'S NAME
CITY OF BARSTOW PARK & RECREATION 760-718-5644
IF THE APPLICANT IS AN ORGANIZATION, PLEASE LIST THE PRIMARY CONTACT TELEPHONE NUMBER EMAIL 760-718-5644 [email protected]
CHELSEA PHILLIPS
CITY STATE ZIP
ORGANIZATION / APPLICANT'S PHYSICAL ADDRESS 92311
220 E MOUNTAIN VIEW ST STE A BARSTOW CA
CITY STATE ZIP
ORGANIZATION / APPLICANT'S MAILING ADDRESS
SAME
PROPERTY OWNER INFORMATION SAME AS APPLICANT
TELEPHONE NUMBER
PROPERTY OWNER'S NAME
CITY STATE ZIP
ADDRESS
EVENT INFORMATION
PRESENT USE OF PROPERTY (i.e. park, parking lot, etc.)
LOCATION / ADDRESS OF EVENT HARVEY HOUSE /PARKING LOT
HARVEY HOUSE / CHRISTMAS TREE LIGHTING
EVENT NAME
CHRISTMAS TREE LIGHTING
FULL DESCRIPTION OF EVENT & ACTIVITIES
HOLIDAY ACTIVITES, VENDORS, & TREE LIGHTING CEREMONY
EVENT TIME (Setup to Teardown) ESTIMATED NUMBER OF ATTENDEES
EVENT DATE
12/06/2024 5:00 DAM/SPM to 9:00 DAM/PM 200
EVENT DETAILS
WILL THE EVENT INCLUDE ANY OF THE FOLLOWING ACTIVITIES:
VENDORS/DONATORS/ If yes, please provide a listing with this application. Please include their business name, YES •NO contact name, phone number, and City of Barstow Business License No.
ENTERTAINERS?
The use of City property or right-of-way includes the use of public parking lots, parks, streets, and sidewalks. If yes, please contact the City of Barstow's Engineering Department regarding the Encroachment Permit application process at 760) 255- USE OF CITY PROPERTY •YES •NO 5161 if the use of a public sidewalk, street, or right-of-way is being requested as part of OR RIGHT-OF-WAY? your event. If use of a public park or park facility is requested, please contact the Parks & Recreation Department at (760) 255-5217 for information regarding use of a City fayes, please contact the City of Barstow's Engineering Department regarding the STREET CLOSURE / OYES •NO
TRAFFIC CONTROL? Encroachment Permit application process at (760) 255-5161. •NO If yes, please provide a listing with the number and types of animals. Also, please ANIMALS? •YES contact the Barstow Humane Society at (760) 252-4800 for approval/inspection.
VEHICLES/EQUIPMENT? DYES •NO If yes, please provide a listing of the types of vehicles/equipment being used.
If yes, please contact San Bernardino County Environmental Health Services (EHS) at FOOD/BEVERAGE? •YES •NO (800) 442-2283 for permitting requirements. Event Organizer - copy of TFF application with SR Number must be furnished with this application.
If yes, please contact the State of California Department of Alcohol Beverage Control ALCOHOL? •YES •NO (ABC) at (760) 324-2027. A copy of the ABC permit must be furnished with this application.
If yes, contact the City of Barstow's Building Department at (760) 255-5161 for CARNIVAL RIDES? •YES •NO information on obtaining the necessary Building and Fire permits.
How many electrically driven? Mechanically driven?
If yes, please identify the location of signs on the site plan.
SIGNS? •YES •NO
How many signs?
If yes, please identify the location of loud speaks) on the site plan.
LOUDSPEAKERS)? •YES •NO
How many loudspeakers?
If yes, please identify the location(s) on the site plan. To setup trash/recycling services TRASH/RECYCLING •YES LINO for your event, please contact Burrtec Waste at (760) 256-2730.
CONTAINERS? How many?
If yes, please identify the location (s) and specify the type on the site plan.
LIGHTING (Portable or •YES •NO
Otherwise)? How many?
• Tents How Many?
PORTABLE STRUCTURES • Trailers How Many?
(Tents, Trailers, Portable •YES •NO How Many?
•Portable Toilets
Toilets, Stages)?
•Stages How Many?
If yes, please provide the following information:
USE OF PRIVATE OYES • NO Name of Security Company
SECURITY? Business License No:
Phone Number:
INSPECTION REQUIREMENTS
An inspection conducted by the Building & Safety Department / Fire Department will be required for special events.
EVENT CONTACT RESPONSIBLE FOR INSPECTION TELEPHONE NUMBER INSPECTION FEES (Due at permit issuance):
• Weekday Event (Monday - Friday) - $85.00 • Weekend Event (Saturday - Sunday) - 2 Hour Min. - $181.10
INSURANCE REQUIREMENTS
AMOUNT OF LIABILITY INSURANCE* NAME OF INSURER
*If the event will be conducted within the City of Barstow's right-of-way or on City property, the City must be named as an additional insured. A minimum of $1,000,000 per occurrence and in the aggregate are required. Depending on the event, additional coverage amounts may be required.
A COPY OF THE INSURANCE CERTIFICATION MUST BE ATTACHED TO THIS APPLICATION
APPLICATION SUBMITTAL CHECKLIST
Completed and signed application. Please note that this application MUST BE signed by the Property Owner, in addition to the applicant. If the Property Owner is unable to sign this application, a notarized original letter of authorization must be attached.
Certificate of Insurance. If your event is located within the City of Barstow's right-of-way (i.e. sidewalks, streets) or on City property (i.e. parks, Harvey House, or other City-owned facility), the City of Barstow MUST BE named as an additional insured.
ALL TEMPORARY USE PERMIT APPLICATIONS must be accompanied by a site plan of the event that shows the event route (if the event is a parade, race (or similar event), street fair, or block party). Additionally, as applicable to the event, the site plan must contain the locations of vendors, tents, trailers, portable toilets, electrical equipment (i.e. generators, lighting, speakers, etc.), stages, signs, trash/recycle containers, animal cages, carnival rides, and designated parking areas.
Application for City of Barstow Encroachment Permit, Building Permit, and/or Barstow Fire Protection District Fire Permit, if applicable.
Vendor/Sponsors/Donators Listing, if applicable.
Vehicle Listing, if applicable.
Animal Listing, if applicable.
Copy of Alcohol Beverage Control permit, if applicable.
Copy of San Bernardino County Environmental Health Services Permit if food/beverage will be sold or furnished.
CERTIFICATION
1 (we) hereby certify under penalty of perjury that the information contained herein is true and that incomplete or false information may result in delay of the application or denial thereof.
1 (we) hereby understand approval of this Temporary Use Permit includes conditions and that failure to comply with those conditions will result in revocation of the Temporary Use Permit.
(we) hereby covenant and agree that if any claim, action, or proceeding shall hereafter be brought seeking to hold the City liable on account of any debt iability, or obligation, I (we) will defend the City at my (our) sole expense against any claim or demand, or threats thereof, whether or not well founded and hold the City harmless therefrom, together with reasonable attorney fees and costs in connection with any defense there against. Furthermore, 1 (we) shall indemnify and hold the City harmless from any such debt, liability, or obligation. 1 (we) further certify that we have read Chapter 9.45 of the Barstow Municipal Code and understand the provisions contained therein. (we) understand that it is our responsibility to obtain necessary permits and approvals that may be required by agencies other than the City of Barstow e.g. Barstow Fire District, Environmental Health Department, Alcohol Beverage Control) I (we) further covenant and agree that if the City property or right-of-way is damaged, in the course of this event I (we) will repair and restore such property to its original condition. Alternatively, I agree that the property will be restored by the City at the permittee's expense. I agree to pay the City all APPLICAN as well aycosts (attorney's fees, etc.) associated with the collection plus interest at the prevailing rate. PRINTED NAME melp CHELSEA PHILLIPS 11/12/24
PRINTED NAME DATE
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