CITY OF SAN BERNARDINO
FEE WAIVER REQUEST/SPONSORSHIP FORM
PLEASE PRINT LEGIBLY
Date of Application: 12-20-25 for 1.19.24
/ 1 Banner ($200.00) Install Date: Remove Date:
Location:
BANNER TEXT:
11 Filming Permit ($260.00)
/ 1 Facility Rental $. _ Which Facility?
Date:
Time:
(Begin) (End)
x] $:_1279.20 plus cost of stret
closures
APPLICANT/ ORGANIZATION INFORMATION
YPCS and
SCBC
Name: YouthPower Community Solutions/ Southern California Black Chamber Address: 624 W 4th st, San Bemardino ca 92401
OFFICE USE ONLY
Phone: 909-771-7561
Approval Checklist:
INSTRUCTIONS FOR APPLICATION Type of Program/Event?
Owner/Principals of the Organization?
Name of the Organization?
All application must be accompanied by the following:
Address of the Organization?
Clear Total?
1. Type of Program/Event Clear Department Costs?
2. Owner/Principals of the Organization Proof of Tax Status?
3. Name of the Organization _ Description of the Event?
4. Address of the Organization _Diagram/plot plan of the Event?
5. Clear statement of the total waiver/sponsorship - Lacation f Banners? amount Resident Benefit?
6. Clear statement of departmental costs (requesting _Total Cost Authorized? organization is responsible for obtaining costs from
the appropriate City departments) Recommended for Approval:
7. Proof of Organization Non-Profit/Tax Exempt Status
(example: tax letter stating 501(c)(3) status)
8. Description of the Event Print Name Date
9. Diagram/plot plan of the Event
10. Location f Banner Signature Date
11. Number of San Bernardino residents benefited
Approved:
(estimate)
Authorized for Submittal Date Date
City Manager
CITY OF SAN BERNARDINO
Community Development Department, Planning Division
Office: 201 North E Street, 3'd Floor
Mail: 290 North D Street
SPECIAL EVENT PERMIT San Bernardino, CA 92401
COUNDED TH 1840 APPLICATION Phone (909) 384-7272 • Fax (909) 384-5155 Web address: www.sbcity.org
GENERAL INFORMATION *for City facilities a Facility Use Agreement Application is also required Name of Event: Location of Activity (Address):
Annual Dr. Martin Luther King Jr. Parade 624 W 4th st/ parade down 4th-D st., 2nd, E st.
YouthBuild Inalnd Empire & Southern California Black Chamber of Commerce APRich Wallace Tele989-771-7561
Maling Acress. box 1722 Duarte CA 91009
On- Rich Wallace Tee 909-771-7561
Signature of Applicant
DATE(S)/TIME(S) INFORMATION
Set-up Date(s): 1/19/2026 Time(s): 7am Tear-down Date(s): 1/19/26 Timels: 8pm Date(s) of Activity: From: 1/19/2026 To: 1/19/2026
Hours of Operation:
11am - 6pm
DESCRIPTION OF EVENT
Describe Planned Activities: MLK Parade and expo/ parade down 4th, right on D, right on 2nd, return left on 4th EXPO in YBIE Parking Lot Expected Attendance: 200
Alcoholic beverage sales/on-site consumption: Yes X NO Will food be prepared on site: X_ Yes..No If yes, attach copy of ABC Permit If yes, attach copy of County Health Permit Structures including vendor booths/tents (provided by applicant): X_Yes _ No If yes, type: * Tent _ * Canopy, Booth Fence X. Portable Toilets _ Bleachers X Stage _Other:
Sound System (provided by applicant): X Yes No
If yes, type: _ Bull Horn _ _Siren Amplified Sound System Other:
Electrical (provided by applicant): _ Yes _ NO
If yes, type: X Generator _Temp. Power Pole _ Light String/Booth Lighting_ Pole Lighting/Flood Lights Rides/Generators Other:
PROPERTY OWNER AUTHORIZATION (for non-City facilities only) DI Property Owner • Agent (A letter of authorization is required to be submitted along with signature below) Name (Please Print): Shiekh Ellah Title: owner
Mailing Address: 494 North E Street San Bernardino CA 92401 Phone: 510-754-6916 Signature Authorizing this Application: Date:
ACTION
• Approved By: • Denied By:
Comments:
Permit Number: Application Date: Received By: Receipt No: Fee(s) Paid: Fee(s) Due:
SPRCSD 8/7/2017 revised by Planning Division June 2021
SUMMARY OF REGULATIONS FOR
SPECIAL EVENT PERMITS
General Information: No person or entity shall operate, maintain, conduct, advertise, or provide admission for any temporary special event within the City of San Bernardino without possessing a permit for each such temporary special event.
A Special Event in the City of San Bernardino is defined as; group assemblies with more than 100 attendees and/or for a duration longer than three days, circuses, rodeos, and carnival (subject to compliance with Chapter 5.42 of the Municipal Code), Fairs, Festivals and concerts, when not held within premises designed to accommodate such events, such as auditoriums, stadiums, or other public assembly facilities. Food events (more than 3 trucks), and certified Farmers Markets.
Submittal Requirements Checklist:
Site Plan- should include; north arrow and drawing to scale, dimensions and shape of the lot, location and name of abutting streets and alleys, location of nearest off-site structures on the site, placement/locations of tents/canopies, identification of the use(s) within tents/canopies, interior seating plan within tents and method of seating, location, composition and height of all existing and proposed walls and/or fences, location of driveways showing all pints of ingress/egress to the site and event, parking layout showing accessible parking spaces and path of travel from the public right-of-way to the proposed event, location on site landscaping if existing, location of restroom facilities, any equipment, storage, generator, any other materials associated with the event, location of refuse enclosures, and placement/location of temporary signage.
Copy of Facility Reservation application/Authorization Letter, if applicable Copy of County Health Permit, if applicable
Copy of County Fire Department Permit
Copy of ABC License, if applicable
Copy of security contract and potable restroom purchase order, if applicable Copy of certificate of liability insurance
Insurance: Before a Special Event Permit is issued, a certificate of insurance must be submitted. The following may be requirements of your event/organization:
• Minimum $1,000,000 General Liability Limit • On an additional insured endorsement the City, its elected officials, • Minimum $1,000,000 General Automobile Liability officers, and agents are to be named as additional insured • Minimum $1,000,000 Worker's Compensation • Minimum limits of coverage may change depending on event insurance Certificate Attached Insurance Certificate On File Insurance Certificate Not Available Insurance Company: Charity one Insurance Expiration Date: 10/17/2026 Additional fees may apply (i.e. street closures, Police Department Fees, City personnel fees, utilities, facility rental, etc.) Review Process: Once the application is submitted to the Community Development Department, a permit number will be issued.
City staff will route the application and all other associated documents to all applicable departments who will review the application and site plan. Once the Department review is complete, Staff will determine if the permit can be approved. If the event is approved, a letter will be written for the approval which will contain conditions under which the event will be permitted to operate. A copy of this approval letter and event conditions must be kept on site for the duration of the event.
Security and Portable Restrooms: In the event that a carnival/street fair and/or alcohol service will be included in the event, an alcohol garden and security plan will need to be submitted along with a security contract and/or public safety staffing plan for review by the Police Department. Portable restrooms are required when estimated attendance exceeds what the host facility's restrooms can accommodate.
By signing below, I agree to indemnify, hold harmless, and defend the City and its officials, employees, and agents, against all claims, liabilities, and losses arising from activities connected with or undertaken pursuant to the Permit. The City is not liable for any business loss, property loss, or other damage that may result from the use of the Permit, or suspension or revocation of the Name: Rich Wallace Rich Wallace Date: 11/18/2025
_Signature:
SPRCSD 8/7/2017 revised by Planning Division June 2021
Date: December 20th, 2025
Shiekh Ellah
Shiekh: Impact Center
949 North E. Street
San Bernardino, CA, 92401
(510)754-6916
To Whom It May Concern,
I, Shiekh Ellah, the owner of Sheikh Impact Center, located at 624 W 4th Street San Bernardino Ca 92401, hereby grant permission to The Southern California Black Chamber of Commerce, YouthPower Community Solutions, and YouthBuild Inland Empire to use my property for their upcoming parade and extravaganza scheduled for Monday January 19th, 2026.
This permission is granted for the specific purpose of holding the event and its associated activities on the mentioned dates, with the understanding that all activities will be conducted in accordance with local regulations and with respect for the premises and surrounding community.
Please let me know if any further documentation or coordination is needed to ensure a smooth event.
Sincerely,
Shiekh Ellah
Owner/ Founder
мне или
YB
YOUTHBUILD
INLAND EMPIRE
EVENT DESCRIPTION
2025 MLK Jr. Parade and Extravaganza Letter of Intent
YouthBuild Inland Empire is proud to partner with The Southern California Black Chamber of Commerce for our Annual MLK Day parade and Extravaganza.
Attached is the route map and street closure plan.
• Name of The Event Annual Dt. Martin Luther King Jr. Parade and Extravaganza 11 2026
• Date(s) of The Event Monday l9n2ary 2142025
• Set up and move-out dates 1/20/241/20/24 one day only • Details of all the activities to occur at the event Parade startup staging will take place at YouthBuild Inland Empire 624w 4th street suite B.
Stagging will begin at 11:00 am and the parade will start at 12 PM.
Parade will go down 4th street, turn right on "D" street, turn right on "2nd" street, turn right on "E" street, turn left on 4ih street, end back where it started. We will have vendors, music, community booths, First 5 children's zone fun and entertainment at the Extravaganza.
• Estimated number of workers at any one time 15 volunteers • Estimated number of persons to be in attendance at any one time 500 people
• Event representative contact information - Dee Goins, 624 W 4** street Suite B, San Bernardino Ca 92410 909-890-9106
Site representative contact information - Rich Wallace 624 W 4th street Suite B, San Bernardino Ca 92410 909-771-7561
• 555 N. Arrowhead Ave, San Bernardino CA 92401 C 888.395.4408 - YouthBuildInlandEmpire.org Law Offices of
Christian Sopank ord
Regal San Bemarding
Sentrex Legal
San Ber
139 North F Street Document Preparation
ACE Cara bolera
Calornia Department of
Trensota orr Drattict 8
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Public Detender Office N Arrowhead Ave
Consulado de Guatemala
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Wells Fargo Bank
San Bernardino
Sank al Americ al
Deleitament sura
Financial Cintar
Employment
Development Department
N EST internal Ravenue • Consulate of Mexico
service (IRS) Terpayer in San Bernardino
N Arrowhead Ave Cali
Buy 5 Sporting Ga
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Pares a Pecteat Joseph E Bonadiman
& Associates: inc
W 2nd St W 2nd st [email protected]
w 2nd st Go getst w 2nd S1
1200 2A 520230001*_ UNAUS SAN Sant Pied ver Fredict 3gri Street closure
YouthBuild Inland Empire
First
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Trash can
EXIT
EXIT
LIXE
RR and hand First Five Family fun zone
washing sinks
Vendor row Food Vendor row
G street
Folding chairs for seating
First
aid
Cars for car show parking
Stage for entertainment
Cars for car show parking Generator
for power
EXIT
4th street
1/8/26, 2:40 P.M YouthBuild Inland Empire Mail - Permit Confirmation for Dr. Martin Parade Celebration Gmail Janie Williams <[email protected]> Permit Confirmation for Dr. Martin Parade Celebration
EHSCustomerService Thu, Jan 8,
<[email protected]> 2026 at 2:37 PM
To: Janie Williams <[email protected]>
Hello,
Thank you for your email. If no food will be sold or given out at the event; you do not need a health permit from our department.
Thank you,
Amanda Macias
Senior Office Assistant
Department of Public Health
Environmental Health Services
Phone: 800.442.2283
385 N. Arrowhead Ave, 2nd Floor
San Bernardino, CA 92415
https://mail.google.com/mail/u/0/?ik=f61fc3008f&view=pt&search=all&permmsgid=msg-f:1853789929183177245&simpl=msg-f:1853789929183177245 1/9/26, 9:25 AM YouthBuild Inland Empire Mail - Dr. Martin Luther King Celebration M Gmail Janie Williams <[email protected]> Dr. Martin Luther King Celebration
Araceli Mata <[email protected]> Fri, Jan 9, 2026 at 8:39 AM To: Janie Williams <[email protected]>
Good morning Janie.
I spoke with the District Commander that assisted with your event last year, to clarify how we can help with your event.
We are able to provide Traffic Control for your parade route, and a PD booth at the Extravaganza event after.
Unfortunately, as a police department we do not do paid sponsorships. If the above is okay, I will get the staff prepared to assist for your event.
Thank you for reaching out... this sounds like it will be a lot of fun for the community! Araceli Mata, Detective
Community Affairs | Crisis Negotiator
San Bernardino Police Department
710 North D Street
San Bernardino, CA 92401
From: Janie Williams <[email protected]> Sent: Thursday, January 8, 2026 2:11 PM
To: Araceli Mata <[email protected]>
Subject: Dr. Martin Luther King Celebration
Caution - This email originated from outside the City - Verify that the Email display name and Email address are consistent. - Use caution when opening attachments.
https://mail.google.com/mail/u/0/?ik=73f12969af&view=pt&search=all&permmsgid=msg-f:1853857986459170696&simpl=msg-f:1853857986459170696 1/1 YOUTPOW-01 JPRAKASH,
ACORD® DATE (MM/DD/MY)
CERTIFICATE OF LIABILITY INSURANCE 1/8/2026
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 INSURERS), 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 WAIVED, 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 endorsements).
PRODUCER CONTACT
Charity One Insurance Agency, Inc [AC, No, Ext): (626) 815-1550 (AC, No): (626) 815-1552 00 Barranca Street, Suite 417
West Covina, CA 91791 ADDREss: [email protected] INSURERS) AFFORDING COVERAGE NAIG #
INSURERA: Nonprofits' Insurance Alliance of California 011845 NSURED INSURER B:
Youth Power Community Solutions INSURER C:
PO Box 9392 INSURER D:
Ontario, CA 91762
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 POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDL SUBF POLICY NUMBER LIMITS
TYPE OF INSURANCE INSD
A 1,000,000
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE
10/17/2025 10/17/2026 500,000
CLAIMS-MADE X OCCUR X a occurrence
20,000
MED EXP (Any one person?
| PERSONAL & ADV INJURY 1,000,000
2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE
X POLICY | PRODUCTS - COMP/OP AGG 2,000,000
SECT LOC
OTHER:
COMBINED SINGLE LIMI 1,000,000
A AUTOMOBILE LIABILITY Ea accident
ANY AUTO 10/17/2025 10/17/2026 BODILY INJURY (Per person) $ AUTOS ONLY BODILY INJURY (Per accident!|
ROPERTY DAMAG
X AUTO'S ONLY X er acciden
UMBRELLA LIAB OCCUR EACH OCCURRENCE
EXCESS LIAB CLAIMS-MADE _AGGREGATE
DED RETENTION $
STATUTE CTH-
YIN
E.L. EACH ACCIDENT
NIA
E.L. DISEASE • EA EMPLOYEE S
DESCRIFTION OF OPERATIONS below E.L. DISEASE - POLICY LIMITS The City of an Bernardino and Their oticers, enplyes andage are ereby any as add l mal ipse as pertine attached endorsement with respect to operations for which City has issued a permit or authorization.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE ACCORDANCETH THE POLICY PROVISIONSCE WILL BE DELIVERED IN EXPIRATION DATE THEREOF, City of San Bernardino, Et, Al
290 N D Stree
San Bernardino, CA 92401
AUTHORIZE REPRESENTAIVE
Caroline OConnor
ACORD 25(2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: COMMERCIAL GENERAL LIABILITY
CG 20 26 12 19
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED
PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s):
City of San Bernardino, The San Bernardino Redevelopment Department, its Officers, Agents, Employees and Affiliates
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II - Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III - Limits Of Insurance:
with respect to liability for "bodily injury", "property If coverage provided to the additional insured i or "personal and advertising injury' required by a contract or agreement, the most we caused, in whole or in part, by your acts or will pay on behalf of the additional insured is th omissions or the acts or omissions of those acting mon insurance on your behalf: 1. Required by the contract or agreement; or
1. In the performance of your ongoing operations;
2. Available under the applicable limits of
insurance;
2. In connection with your premises owned by or whichever is less. rented to you.
This endorsement shall not increase the
However:
applicable limits of insurance.
1. The insurance afforded to such additional
insured only applies to the extent permitted by
law; and
2. If coverage provided to the additional insured is
required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
CG 20 26 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 NONPROFITS®
INSURANCE NONPROFITS OWN®
ALLIANCE OF CALIFORNIA
Part of Nonprofits Insurance Alliance (NIA)
Policy Number:
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS (WAIVER OF SUBROGATION)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s):
City of San Bernardino, The San Bernardino Redevelopment Department, its Officers, Agents, Employees and Affiliates
Where you are so required in a written contract or agreement currently in effect or becoming effective during the term of this policy, we waive any right of recovery we may have against that person or organization, who may be named in the schedule above, because of payments we make for injury or damage.
NIA-026 GL 11 17 Includes copyrighted material of Insurance Services Office, Inc. with its Page 1 of 1 permission.
GORE Dee Goins <[email protected]>
Your Fire Special Event Permit application has been submitted. 1 message
noreply-ezop <[email protected]> Tue, Nov 18, 2025 at 4:02 PM To: "[email protected]" <[email protected]> Dear Applicant,
Record FSEP-2025-00268, has been successfully submitted through the San Bernardino EZ Online Permitting System (EZOP). ounty Fire may invoice you for any additional required fees within the next few business days to continue the application proces lease note, the review process does not begin until all fees have been paid. The status of your application can be viewed through t EZOP Citizen Access Portal.
What's Next?
Applications are reviewed for completeness within 1-2 business days from date of submittal.:
• Incomplete Applications:
If your application is deemed incomplete or is missing required documents, an email notification will be sent to the applicant that the application has been withdrawn. Please do not create a new application. • Complete Applications:
Once your application is accepted, fees will be generated, and an invoice will be sent to the email address that has been provided by the applicant. Once fees are paid, your plans will be routed for review. Plan check review time is 15-21 days afte payment has been received.
If you have any additional questions, please contact the Office of the Fire Marshal at (909) 386-8400 and reference the project number FSEP-2025-00268.
Thank you,
Office of the Fire Marshal/Community Safety Division
J Type: SEP Vers: 2101 Special Event Permit (Project) • • Case # : SEP26-001 Address: 624W 4TH ST SB
Status: SUBMITTD APPLICANT: RICH WALLACE ccela GIS: Accela • Default View Map View Log Date: |01/06/2026 Back Stop C
Accela GIS: Accela View Map View Log Objects
OK Officeh
Screen Fees Desc People Cond LHIN Loc Doc Relate. Anne
Fee Processing for SEP26-001
Fee Summary
Parcels Calculated Fees: $1,279.20 Pay Full Balance Assess Additional Details Fee
People Additional Fees: $0.00 Details Back
Partial Payment Redistribute
Total Fees: $1,279.20 Details OverPayment
Events
Payments: | Pay Specific Void Payments
$0.00 Details Items)
Trust Accounts
Balance: $1.27920 Fee Loa
Work Flow Reprint Receipt
Include deferred payments in Fee Details:
AVR Log Include Trust transactions in Payment Details: Pay Deferred Bint Grid Exit
Pay Specific - Suppress zero balance items:
ToolBar Order a
'PERMITS' Plus® 32-Bit ©2013-Accela, Inc. All Rights Reserted licensee: SAN BERNARDINO, CA - CIT Serial Number: 6179 Users: 058| Version: v. 5.5.21 Public Works Department
Office: 201 North E Street, 2nd Floor
Mail: 290 North "D" ST San Bernardino, CA 92401
Phone: (909) 384-5140 FAX: (909) 384-5190
ПЕРАЯНТ 1Я Website: www.sbcity.org
RIGHT-OF-WAY PERMIT
Permit No. ROW2600015
Status: ISSUED
Issued Date: 01/13/2026
Applicant: Contractor:
YOUTH POWER COMMUNITY SOLUTIONS & SOCAL YOUTHBUILD IE & SOCAL BLACK CHAMBER OF
BLACK CHAMBEROF COMMERCE COMMERCE
P.O. BOX 9392 P.O. BOX 1722 DUARTE
ONTARIO, CA CA 91009
(909) 771-7561 (909) 771-7561
Insurance expiration date:
Location: 4TH ST, D ST, 2ND ST, E ST
Adjacent Address:624 W 4TH ST SB Insp. Area:
Purpose of Permit: ANNUAL DR MARTIN LUTHER KING JR PARADE AND EXTRAVAGANZA.
Work Order Number:
Date(s): JANUARY 19, 2026
Time(s): 8am - 8pm (No weekends or holidays)
Description Quantity Fee Amount
Lane Closure Days: $0.00
Special Event LC $0.00
Special Event SC $1,495.00
Const. Road Closure: $0.00
Temp. Encroach. Permit (With Lane Closure): $0.00
After Hours Inspections: $751.48
Normal Hours Inspections: $0.00
Miscellaneous Fees:
Issuance Fee: $0.00
Extension Fee: $0.00
Archival Fee: $0.00
Technology Fee: $44.93
Total Fee Amount $2,291.41
COMMENTS: 1: PERMIT VALID FOR ONE (1) DAY ONLY : 01/19/26 • CONTRACTOR TO NOTIFY RESIDENTS 10 DAYS BEFORE ROAD CLOSURE 3: CONTRACTOR SHALL POST TEMP. "NO PARKING" SIGNS 72 HOURS PRIOR TO WORK. 4: CONTRACTOR TO COORDINATE WITH THE BUS AUTHORITY FOR ANY TEMPORARY CLOSURES OR RELOCATIONS.
5: COORDINATION OF NO FEE PERMIT WILL BE DISCUSSED AT CITY COUNCIL 01/21/26. 6: CONTACT: LUE DOWDY 909-567-1000/RICH WALLACE 909-771-7561 Rich Wallace 1/15/26
Applicant's Signature Date Signed
ROSE SILVA 01/15/26
Issued By Date Signed
Public Works Department
300 North D Street, San Bernardino, CA
Ph: 909-384-5111 Fax: 909-384-5190, www.sbcity.org
RIGHT-OF-WAY PERMIT WORKSHEET
Permit No. ROW2600015 Sent to
Status: APPLIED Dee 01/09/26
Issued Date:
Applicant: Contractor:
YOUTH POWER COMMUNITY SOLUTIONS & YOUTHBUILD IE & SOCAL BLACK CHAMBER
SOCAL BLACK CHAMBEROF COMMERCE OF COMMERCE
P.O. BOX 9392 P.O. BOX 1722 DUARTE
ONTARIO, CA CA 91009
(909) 771-7561 (909) 771-7561
Insurance expiration date:
Location: 4TH ST, D ST, 2ND ST, E ST
Adjacent Address: 624 W 4TH ST SB Insp. Area:
Purpose of Permit: ANNUAL DR MARTIN LUTHER KING JR PARADE AND EXTRAVAGANZA.
Work Order Number:
Date(s): JANUARY 19, 2025
Time(s): 8am - 8pm (No weekends or holidays)
Description Quantity Fee Amount
Lane Closure Days: $0.00
Special Event LC: $0.00
Special Event SC: $1,495.00
Const. Road Closure: $0.00
Temp. Encroach. Permit (With Lane Closure): $0.00
After Hours Inspections: $751.48
Normal Hours Inspections: $0.00
Miscellaneous Fees:
Issuance Fee: $0.00
Extension Fee: $0.00
Archival Fee: $0.00
Technology Fee: $44.93
Total Fee Amount $2,291.41
Amount Received $0.00
Balance Due $2,291.41
Disasiong no fee will take place on katale
City of San Bernardino Assigned Activity #
Public Works Department ROW 2600015
300 N. D Street (Office Use Only)
San Bernardine San Bernardino, CA 92401 **Right of Way ** (909) 384-7272
[email protected] Permit Application
** General Information **
Job Address / APN / Location: 624 W 4th st/ parade down 4th, d st, 2nd, E st Nearest Cross Streets): 4th, D st, 2nd, E St
Purpose of Permit: Annual San Bernardino Dr. Martin Luther King Jr Parade Utility (Circle): Cable Electric Telephone Gas Sewer Water Other:
Work Order #: Dates of Work: Monday January 19th, 2026
Times of Work (If Different from Mon - Fri, 8am - 4pm, no Holiday/Wends): parade starts at 11 end at 1pm ** Lane / Road Closure **
Lane Closure - # of Construction Days: Lane Closure - # of Special Event Days:_ Road Closure - # of Construction Days: Road Closure - # of Special Event Days:
** Excavation **
Excavation - # of Days: Total Length: Total Width:
** Encroachment **
Encroachment Only, No Lane Closure - # of Days:_ Permanent Encroachment (Y/N):
24 Hour Notice Required Prior to Work Being Done Call (909) 384-7272 Contractor Information (Please Print):
Company Name and Address: Rich Wallace 909-771-7561, Lue dowdy 909-567-1000 Co. Phone # (909) 567-1000 Contact Name: Lue Dowdy Contact Ph #:
City of SB Bus Lic # & Exp Date: CSLB Lic #, Class & Exp Date:
General Liability Ins Co: Charity One Insurance _GL Policy # GL Policy Exp Date: 10/17/2026 Applicant Name (Please Print): Richard Wallace Applicant signature: Rich Wallace Office Use Only: ( Do not Write Below This Line)
Date: ROW Permit # On / Off-Site Permit #
YOUTPOW-01 ADMIN
ACORD® DATE (MM/DDAYYY)
CERTIFICATE OF LIABILITY INSURANCE 11/5/2025
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
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.
SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement c is certificate does not confer rights to the certificate holder in lieu of such endorsements
PRODUCER
Charity One Insurance Agency, Inc (AC, No, Ext: (626) 815-1550 [AC, No): (626) 815-1552 00 Barranca Street, Suite 417
West Covina, CA 91791 MEss: [email protected] INSURERS) AFFORDING COVERAGE NAIC #
INSURERA: Nonprofits' Insurance Alliance of California 011845 INSURED INSURER B:
Youth Power Community Solutions INSURER C:
PO Box 9392 INSURER D:
Ontario, CA 91762
INSURERE:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
EXCLUSIONS AND CONDIONS OFSUCH POLICIES: IMS SHOWN MAY HAVE BEREDUCED BY PAD LED HERE IS SUBECT TOALL THE TERMS,
INSR LIMITS
TYPE OF INSURANCE POLICY NUMBER
1,000,000
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE
CLAIMS-MADE X OCCUR x 10/17/2025 10/17/2026 AMAGE TO RENTE $ 500,000 : × PREMISES (Ea occurrence
MED EXP (Any one person) $ 20,000
1,000,000
PERSONAL & ADV INJURY $
$ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,000,000 X POLICY LOC PRODUCTS - COMP/OP AGG $
OTHER: $
A $ 1,000,000
AUTOMOBILE LIABILITY
ANY AUTO 10/17/2025 10/17/2026 BODILY INJURY (Por person) $
AUTOS ONLY
X AUROS ONLY
UMBRELLA LIAB OCCUR EACH OCCURRENCE
EXCESS LIAB CLAIMS-MADE AGGREGATE
DED RETENTION$
STATUTE
Y/ N
N/ A E.L. EACH ACCIDENT
Ring THREE NEXECUTIVE
E.L. DISEASE • EA EMPLOYEE S
DES OPERATIONS BElON E.L. DISEASE - POLICY LIMIT S
Phe City of san Bernardino and their ovicers, mployees and age is are reby mayd as adit on insureds per the attached endorsement with respect to operations for which City has issued a permit or authorization.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of San Bernardino ACCORDANCE WIH THE POLICY PROVISIONSCE WILL BE DELIVERED IN 300 N. D St.
San Bernardino, CA 92418
AUTHORIZED REPRESENTATIVE
Caroline OConnor
ACORD 25(2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: 01-CP-0037999-01-12 COMMERCIAL GENERAL LIABILITY CG 20 26 12 19
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED
PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s):
City of San Bernardino, The San Bernardino Redevelopment Department, its Officers, Agents, Employees and Affiliates
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II - Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III - Limits Of Insurance:
with respect to liability for "bodily injury", so to arina bad adversing perty If coverage provided to the additional insured is damage"
caused, in whole or in part, by your acts or vil pay on behalf of the aditional insured ste omissions or the acts or omissions of those acting amount of insurance:
on your behalf: 1. Required by the contract or agreement; or
1. In the performance of your ongoing operations; 2. Available under the applicable limits insurance;
2. In connection with your premises owned by or whichever is less. rented to you.
However: This endorsement shall not increase the
applicable limits of insurance.
1. The insurance afforded to such additional
insured only applies to the extent permitted by
law; and
2. If coverage provided to the additional insured is
required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
CG 20 26 12 19 © Insurance Services Office, Inc., 2018 Page 1 of 1 NONPROFITS®
INSURANCE NONPROFITS OWN®
ALLIANCE OF CALIFORNIA
Part of Nonprofits Insurance Alliance (NIA)
Policy Number:
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS (WAIVER OF SUBROGATION)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s):
City of San Bernardino, The San Bernardino Redevelopment Department, its Officers, Agents, Employees and Affiliates
Where you are so required in a written contract or agreement currently in effect or becoming effective during the term of this policy, we waive any right of recovery we may have against that person or organization, who may be named in the schedule above, because of payments we make for injury or damage.
NIA-026 GL 11 17 Includes copyrighted material of Insurance Services Office, Inc. with its Page 1 of 1 permission.
01/19/26 MLK Parade staging: @11 am
Parade start: @12 pm
Parade end: ~@2pm
TCP: 6am to 3pm
Row2600015
TANSAT Sign Placement placed 72 hours in advance.
SHE SI
PUBLIC WORKS DEPARTMENT/ENGINEERING CITY OF SAN BERNARDINO
NO EXCEPTIONS TAKEN
MAKE CORRECTIONS NOTED &
RESUBMIT WITHIN 5 DAYS
¡TV DATE: 01/09/26
BY:_
01/19/26 MLK Parade staging: @11 am
Parade start: @12 pm
Parade end: ~@2pm
TCP: 6am to 3pm
5th and G: Detour Left for WB vehicles and Detour Right for NB vehicles PLW
DETOUR
DRN
5th and F: Detour Right for SB Vehicles approaching the Road Closed to Thru Traffic sign (R11-4) DRS
CITY OF SAN BERNARDINO
PUBAIG WORKS DEPARTMENT/ENGINEERING
NO EXCEPTIONS TAKEN
MAKE CORRECTIONS NOTED &
RESUBMIT WITHIN 5 DAYS
DATE: 01/09/26
BY:
01/19/26 MLK Parade staging: @11 am
Parade start: @12 pm
Parade end: ~@2pm
TCP: 6am to 3pm
5th and E: Detour Right for SB, Detour Left for NB, and one R11-4 9 02
CITY OF SAN BERNARDINO
PUBIG WORKS DEPARTMENT/ENGINEERING NO EXCEPTIONS TAKEN
MAKE CORRECTIONS NOTED &
ESUBMIT WITHIN 5 DAYS
PEDEN DATE 01/09/26
BY:_
5th and Stoddard and D: Detour signs as indicated
DRS
W 5in St
DETOUR
DIN
01/19/26 MLK Parade staging: @11 am
Parade start: @12 pm
Parade end: ~@2pm
TCP: 6am to 3pm
and Arrowhead: Detour signs as indicated
CITY OF SAN BERNARDINO
DETORR PLEN NO EXCEPTIONS TAKEN MERING NO EXCEPTIONS TAKEN RE
MAKE CORRECTIONS NOTED &
RESUBMIT WITHIN 5 DAYS
Blin DONE 01/09/24
BY:
01/19/26 MLK Parade staging: @11 am
Parade start: @12 pm
Parade end: ~@2pm
TCP: 6am to 3pm
3rd and H/G: one R11-4
CITY OF SAN BERNARDINO
PUBING WORKS DEPARTMENT ENGINEERING NO EXCEPTIONS TAKEN
MAKE CORRECTIONS NOTED &
RESUBMIT WITHIN 5 DAYS
DATE 01/69/26
BY:_
W are St
W 3rd St
01/19/26 MLK Parade staging: @11 am
Parade start: @12 pm
Parade end: ~@2pm
TCP: 6am to 3pm
4"h and G: Hard closure EB, tapper to restrict SBLT with R3-2, and Detour signs as indicated. 2 CITY OF SAN BERNARDINO
PUBAIQ WORKS DEPARTMENT/ENGINEERING
NO EXCEPTIONS TAKEN
MAKE CORRECTIONS NOTED &
BESMENT WITHIN 501649/26
Sir DATE:
NLS - BY:
DR
01/19/26 MLK Parade staging: @11 am
Parade start: @12 pm CITY OF SAN BERNARDINO
NO EXCEPTIONS TAKEN
Parade end: ~@2pm
MAKE CORRECTIONS NOTED &
RESUBMIT WITHIN 5 DAYS
TCP: 6am to 3pm 01/09/24
BY: _DATE:
4th and F: Hard closure SB with R11-2 north of driveway, three Type 1 barricades at each barricade icon.
1RD0RA
V 48h ST
01/19/26 MLK Parade staging: @11 am
Parade start: @12 pm
CITY OF SAN BERNARDINO
PUBLIG WORKS DEPARTMENT/ENGINEERING
Parade end: ~@2pm NO EXCEPTIONS TAKEN
MAKE CORRECTIONS NOTED &
RESUBMIT WITHIN 5 DAYS
TCP: 6am to 3pm 01/09/24
BY:_ _DATE:
4th and E: Hard closure NB with R11-2, three barricades at each driveway.
Da Nin 8t
01/19/26 MLK Parade staging: @11 am
Parade start: @12 pm
CITY OF SAN BERNARDINO
PUBIC WORKS DEPARTMENT/ENGINEERING
Parade end: ~@2pm NO EXCEPTIONS TAKEN
MAKE CORRECTIONS NOTED &
RESUBMIT WITHIN 5 DAYS
TCP: 6am to 3pm DATE: 01/09/26
BY:_ LillA
4th and Stoddard/D: Diagonal closure with two R11-2, tapper and restrict conflicting turns with signs, 3 barricades per driveway.
94: 0
01/19/26 MLK Parade staging: @11 am
Parade start: @12 pm
CITY OF SAN BERNARDINO
Parade end: ~@2pm NO EXCEPTIONS TAKEN
MAKE CORRECTIONS NOTED &
TCP: 6am to 3pm RESUBMIT WITHIN 5 DAYS
DATE: 01/09/24
BY:
4th and Arrowhead: One R11-4
01/19/26 MLK Parade staging: @11 am
Parade start: @12pm
Parade end: ~@2pm
TCP: 6am to 3pm
Along Court St: 3 barricades at each driveway, 6 on each side of E St.
Along 3r° St: WB hard closure, EB detour sign, R11-2, R11-4, and 3 barricades at each driveway.
W Sie St
DETOUR
DLW
NArrowne
CITY OF SAN BERNARDINO
PUBER WORKS EATEN ENGINEERING NO EXCEPTIONS TAKEN
MAKE CORRECTIONS NOTED &
RESUBMIT WITHIN 5 DAYS
_DATE: 01/09/24
01/19/26 MLK Parade staging: @11 am
Parade start: @12 pm
Parade end: ~@2pm
TCP: 6am to 3pm
2nd St and F St: R11-4, one Detour right sign for EB
W 2nd S1
ID RI E
CITY OF SAN BERNARDINO
PUB EPARIOIN TANEINEERING NO EXCEPTIONS TAKEN
MAKE CORRECTIONS NOTED & RESUBMIT WITHIN 5 DAYS
Psilva DATE: 01/09/24
BY:
01/19/26 MLK Parade staging: @11 am
Parade start: @12 pm
Parade end: ~@2pm
TCP: 6am to 3pm
2nd St and E St: Diagonal closure with 2 R11-2 and detour and signs, taper and sign restrict opposing turns. 3 barricades at KORE driveway.
Vi Rue S W 2nd St W 20d
2nd gl ne Si W206 81
ETOD
RE
72 D
PUBIE WORKS DEPARTMENT/ENGINEERING CITY OF SAN BERNARDINO
NO EXCEPTIONS TAKEN
MAKE CORRECTIONS NOTED &
RESUBMIT WITHIN 5 DAYS
_ DATE: 01/09/24
BY:
01/19/26 MLK Parade staging: @11 am
Parade start: @12 pm
Parade end: ~@2pm
TCP: 6am to 3pm
2nd and Stoddard: 3 barricades at each driveway
W 2nd St W 2nd St
W 2nd St W 2nd St W 2nd St
CITY OF SAN BERNARDINO
NO EXCEPTIONS TAKEN
MAKE CORRECTIONS NOTED & RESUBMIT WITHIN 5 DAYS
_DATE: 01/09/26
01/19/26 MLK Parade staging: @11 am
Parade start: @12 pm
Parade end: ~@2pm
TCP: 6am to 3pm
2° and D: Diagonal closure with 2 R11-2 and detour signs, tapper and sign restrict opposing movements, 3 barricades at each driveway
01/19/26 MLK Parade staging: @11 am
Parade start: @12 pm
Parade end: ~@2pm
TCP: 6am to 3pm
CITY OF SAN BERNARDINO
PUBLIC WORKS DEPARTMENT/ENGINEERING
NO EXCEPTIONS TAKEN
MAKE CORRECTIONS NOTED &
RESUBMIT WITHIN 5 DAYS
01/09ka
BY:_ _DATE,
UR
W
NRWO
MIN BETORN
01/19/26 MLK Parade staging: @11 am
Parade start: @12 pm
Parade end: ~@2pm
TCP: 6am to 3pm
2nd and Arrowhead: R11-4 and detour signs
DETOUR
DLW
DETOUR
DLE
Along Rialto: SB detour signs and 2 R11-4 CITY OF SAN BERNARDINO
PUBLIC WORKS DEPARTMENT/ENGINEERING
NO EXCEPTIONS TAKEN
MAKE CORRECTIONS NOTED &
RESUBMIT WITHIN 5 DAYS
01/09/26
DATE:
BY:
01/19/26 MLK Parade staging: @11 am
Parade start: @12 pm
Parade end: ~@2pm
TCP: 6am to 3pm
PUBLIC WORKS DEPARTMENT/ENGINEERING CRY OF SAN BERNARDINO
NO EXCEPTIONS TAKEN
MAKE CORRECTIONS NOTED & RESUBMIT WITHIN 5 DAYS
• BRO ONE 01/09/24