N Special Event Permit Application
CITY OF Recreation & Park Services Department
NORWALK 13000 Clarkdale Avenue • Norwalk, CA 90650
562-929-5566 • www.norwalk.org • [email protected] A Connected Community
ONLY COMPLETE APPLICATIONS WITH PAYMENT WILL BE ACCEPTED Block Concert Festival/ Fundraiser vendor Live Parade
Event Type: CITY STAFF
Party Carnival Market Music Processions
Race/ Sale/ Car Tournament Other: FEE: _
Walk Expo Show STAFF INITIALS:
Is this a repeat event? Yes - If yes, what date was the event last held? APR. DATE:
Event Title: Practice Parade for the 605 All Star Band
Event Dates): Sunday, Dec. 22, 2024 _ Event Start & End Time: 1:30PM 103:30 pM 12/22/24
Setup Date & Time: 12/22/24 Noon Break Down Date & Time: 4:00 pM Attendance Per Day: Participants Per Day: 565_ Admission Fee: D NO YES -Method?:_ Observe from the curb
Open to Public?: NO VYES - Describe: Phone #/website for public info:
Event Exact Adres Beg in ingo. John bleno s Site Plan Attached:
13520 Shoemaker Ave Norwalk, CA 90650
APPLICANT INFORMATION
(If a professional event organizer is applying for this permit, a letter from the Chief Officer of the organization authorizing the organizer is required.)
Authorized For Profit
Applicant: Thomas Philips -605 All Star Band Non- Profit Contact BWJD.KIZ.CA.US
Thomas Philips Email: Philips@ Phone: 562-212-2763
Person:
4067 Hardwick st
Address: p.o. 50X 180 City, State, ZIP: Lakewood Cell: 562-212-2263 CA 90112
List information of professional organizer or event planner hired for this event, if applicable:
Name: Email: Phone:
Address: City, State, ZIP: Cell:_
Day of Event "on-site" contacts):
(Person(s) must be in attendance for the duration of the event and immediately available to City Officials.) Thomas Philips Phone: 567-212-2263
Name:
Frank Minojoz Email: thino joz @ Phone: 567-824-4489
Name:
NIMUSD.KIZ.CA.US
CITY OF NORWALK
RECREATION AND PARK SERVICESDEPARTMENT
Parent
Will all or any part of the event take place on City of Norwalk property? YES Volunteers
Does the event applicant have any empreyes that wil be working at the event? No YES
EVENT DETAILS
Describe parking arrangements in detail for event: Is plan attached? NO YES Parking & Traffic
VNO LVI YES, Describe: City of Norwalk will
Traffic Equipment Required? |/
(e.g. reader boards, barricades, cones, etc) provide Map of, Parade Route List streets that require *closure for this event: as per Richard Newton *Road closure permit required
Provide a detailed traffic plan for road closures. Is the plan attached? V NO Entertainment (Amplified sound requires onsite contact) Band will perform on a detailed
List ALL entertainment & related activities:
parade route.:
Will event have
YES Sound Contact
amplified sound? NO ndoors Outdoors Name & Number:
Describe hours, sound equipment & type of use (eg. speakers, amplifiers, generators, etc.):
Will the Special Event include a valet or shuttle service? _ YES, DESCRIBE:
Will there be fireworks or other pyrotechnics? NO YES, DESCRIBE:
Will there be a A Drawing L Casino - Company Name & Number: _ As a reminder there is no gambling allowed in The City of Norwalk at any time.
Alcohol & Food
Alcohol at event? X-vo served sold Name & Number:
Food at event? Ano served -Sold Name donumber:
Will food be prepared at the event? I No YES
Marketing
Describe marketing plan in detail for event: Is plan attached? Ino ElvEs on line advertising
CITY OF NORWALK
RECREATION AND PARK SERVICESDEPARTMENT
Structures & Other Equipment
Will there be canopies or tents? NO YES, If yes, size & quantity Date installed: Date removed: Supplier Name:
Will booths, bleachers, stages,
or structures be erected? No Yes, Describe:
Will signs or banners be used? No Yes, Describe:
Will there be generators, vehicles
boats or other equipment? Yes, Describe:
Will there be Carnival Rides Attractions, Describe:
Will there be commercial filming of this event?
Any other commercial aspects?
Additional information:
AGREEMENT & PAYMENT INFORMATION
I, the undersigned, acknowledge and understand that I am responsible to comply with the information, restrictions and conditions of the permit. I hereby acknowledge responsibility for penalties associated with non-compliance with the permit conditions, whether or not I am present at the time of the violation.
IP Initials
I hereby certify the foregoing statements to be true and correct, and agree to defend, indemnify and hold harmless the City of Norwalk, its City Council, officers, agents, employees and volunteers from and against any and all loss, claims, damages, liability, such claim or suit arising from or in any manner connected to the requested activity. I also agree, if approved, to comply with all permit conditions, and understand that failure to comply with any condition or any violation of law may result in the immediate cancellation of the event, denial of future events, and or criminal prosecution.
Failure to comply with permit conditions can result in revocation of the permit, forfeiture of deposit, administrative citations, fines and denial of future permit applications.
Thomas Philips Thomas to Philips 19/6/24
Print Name Signature
Application(s) must be complete with all necessary attachments in order to be accepted & processed. (Insurance, event diagrams, parking plans, community notification, vendor list, other permits, etc.) NEW
Firewal of Number United States Liability Insurance Company 1190 Devon Park Drive, Wayne, Pennsylvania 19087 Direct Bill Policy POLICY DECLARATIONS A Member Company of United States Liability Insurance Group No. CUP1577479
NAMED INSURED AND ADDRESS:
605 ALL STAR BAND
4067 HARDWICK ST
LAKEWOOD, CA 90712
POLICY PERIOD: (MO. DAY YR.) From: 07/02/2024 To: 07/02/2025 12:01 A.M. STANDARD TIME AT YOUR FORM OF BUSINESS: Non Profit Organization MAILING ADDRESS SHOWN ABOVE:
IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY.
THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED.
THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT.
PREMIUM
Commercial Umbrella Coverage $651.00
Wholesaler Broker Fee $150.00
TOTAL: $801.00
Coverage Form(s) and Endorsements) made a part of this policy at time of issue See Endorsement EOD (1/95)
Agent: BTIS (5195)
6610 Sierra College Blvd Issued: 07/08/2024 2:57 PM
Rocklin, CA 95677
Broker: Kingshill Insurance Services, LLC
1240 N Van Buren St, Suite 211 By:
Anaheim Hills, CA 92807 Authorized Represe native
UPD (08-07)
COMMERCIAL UMBRELLA COVERAGE DECLARATIONS
Policy No. CUP1577479
Effective Date: 07/02/2024
12:01 AM STANDARD TIME
LIMITS OF INSURANCE
Each Occurrence Limit $1,000,000
General Aggregate Limit $1,000,000
SELF INSURED RETENTION
$0
LOCATION OF COVERAGE
Location Address
Territory
PER UNDERLYING POLICY/POLICIES
SCHEDULE OF UNDERLYING INSURANCE ATTACHED
Coverage Forms)/Parts) and Endorsements) made a part of this policy at time of issue:
See Form EOD (01/95)
THESE DECLARATIONS ARE PART OF THE POLICY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND THE POLICY PERIOD.
CUP 150(03/11) cludes copyrighted material of ISO Commercial Risk Services, Inc., with its permissi pyright, ISO Commercial Risk Services, Inc., 1983, 1984. 19 Page 1 of 1 Department of the Treasury Date:
Internal Revenue Service 05/20/2024
Tax Exempt and Government Entities Employer ID number:
IRS P.O. Box 2508 93-3229568
Cincinnati, OH 45201 Person to contact:
Name: Customer Service
ID number: 31954
Telephone: 877-829-5500
605 ALL STAR BAND Accounting period ending:
6637 FAIRMAN ST December 31
LAKEWOOD, CA 90713 Public charity status:
170(b)(1)(A) (vi)
Form 990 / 990-EZ / 990-N required:
-Yes.
Effective date of exemption:
August 25, 2023
Contribution deductibility:
Yes
Addendum applies:
No
DLN:
26053529006374
Dear Applicant:
We're pleased to tell you we determined you're exempt from federal income tax under Internal Revenue Code (IRC) Section 501(c)(3). Donors can deduct contributions they make to you under IRC Section 170. You're also qualified to receive tax deductible bequests, devises, transfers or gifts under Section 2055, 2106, or 2522. This letter could help resolve questions on your exempt status. Please keep it for your records.
Organizations exempt under IRC Section 501(c)(3) are further classified as either public charities or private foundations. We determined you're a public charity under the IRC Section listed at the top of this letter.
If we indicated at the top of this letter that you're required to file Form 990/990-EZ/990-N, our records show you're required to file an annual information return (Form 990 or Form 990-EZ) or electronic notice (Form 990-N, the e-Postcard). If you don't file a required return or notice for three consecutive years, your exempt status will be automatically revoked.
If we indicated at the top of this letter that an addendum applies, the enclosed addendum is an integral part of this letter.
For important information about your responsibilities as a tax-exempt organization, go to www.irs.gov/charities.
Enter "4221-PC" in the search bar to view Publication 4221-PC, Compliance Guide for 501(c)(3) Public Charities, which describes your recordkeeping, reporting, and disclosure requirements.
Sincerely,
stephere a. marten
Stephen A. Martin
Director, Exempt Organizations
Rulings and Agreements
Letter 947 (Rev. 2-2020)
Catalog Number 35152P