CITY OF SAN BERNARDINO
FEE WAIVER REQUEST/SPONSORSHIP FORM
PLEASE PRINT LEGIBLY
Date: 1.21.2026
[ ] Banner ($200.00) Install Date: Remove Date:
Location:
BANNER TEXT:
11 Filming Permit ($260.00)
[ ] Facility Rental $. Which Facility?
Date:
Time:
(Begin) (End)
[ x ] Other-Special Event Permit: Proposed for the Black History Parade 2026 parade and exposition event occurring on baseline street starting from Graciano Gomez Elementary School
Special Event Fee: $1279.20
: $ 1912.44
Public Work Fee:
Police Dost. Fee M6, 150,15
• Total $9,297.09
APPLICANT/ORGANIZATION INFORMATION
OFFICE USE ONLY
Name: Black Culture Foundation
Approval Checklist:
Address:2407 W. Victoria Street, SB CA 92410
_Type of Program/Event?
Phone: 909.534.9500 Owner/Principals of the Organization? Name of the Organization?
INSTRUCTIONS FOR APPLICATION:All application must Address of the Organization? be accompanied by the following: Clear Department Costs? Proof of Tax Status?
1. Type of Program/Event Description of the Event?
Diagram/plot plan of the Event?
2. Owner/Principals of the Organization
Location f Banners?
3. Name of the Organization Resident Benefit?
Address of the Organization Total Cost Authorized?
5. Clear statement of the total waiver/sponsorship
Recommended for Approval:
Clear statement of departmental costs (requesting
organization is responsible for obtaining costs from
the appropriate City departments) Print Name Date
Proof of Organization Non-Profit/Tax Exempt Status
(example: tax letter stating 501(c)(3) status)
Signature Date
8. Description of the Event
9. Digeram/plot plan of the Event Approved:
10. Vocation 1 Banne
11 Number of aruino residents benefited
• 1.21.2026
-City Manager Date
Date
-
CITY OF SAN BERNARDINO
Community Development Department, Planning Division
Office: 201 North E Street, 3° Floor
Mail: 290 North D Street
SPECIAL EVENT PERMIT San Bernardino, CA 92401
HINDED IN 1019 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 cation of Activity (Address
Name of Event: The Black History Parade aseline Ave Mt. Vernon to Arroyo High Schoc Organization Name: The Black Culture Foundation
Applicant Name: Carl M. Dameron Telephone: 909-534-9500 Malling Address: 2407 W Victoria Street, SB CA 92410
On-Site Contact Name: Carl M. Dameron Telephone: 909-534-9500 Signature of Applicant Carl Maurice Dameron Date Signed 1/13/26
DATE(S)/TIME(S) INFORMATION
Set-up Date(s): 2/7/26 Timels): 6:00 am Tear-down Date(s): 2/7/26 Times) 11:00 am Date(s) of Activity: From: Febuary 27, 2026 To: Febuary 27, 2026 Hours of Operation: 6:00 am to 11:00 am
DESCRIPTION OF EVENT
Describe Planned Activities: Parade from Mt Vernon Ave to Arro High School Expected Attendance:
Alcoholic beverage sales/on-site consumption: Yes X_No Will food be prepared on site: _ Yes X 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 _X_ Booth Fence Portable Toilets Bleachers Stage Other:
Sound System (provided by applicant): Yes NO
If yes, type: _ Bull Horn Siren _X Amplified Sound System Other:
Electrical (provided by applicant): _ _Yes X_ No
If yes, type: _Generator Temp. Power Pole Light String/Booth Lighting, _Pole Lighting/Flood Lights Rides/Generators Other:
PROPERTY OWNER AUTHORIZATION (for non-City facilities only) • Property Owner • Agent (A letter of authorization is required to be submitted along with signature below) Name (Please Print): David Chavez San Bernardino City Unified School District Title: Multimedia manager Mailing Address: Phone: (909) 381-1250
777 North F Street, San Bernardino, CA 92410
Signature Authorizing this Application: Carl Maurice Dameron Date: 1/13/26 ACTION
• Approved By: • Denied By:
Comments:
Permit Number: Application Date: Received By: Receipt No: Fee(s) Paid: Fee(s) Due:
SBPRCSD 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. Applications must be turned in 30 business days prior to the event but no sooner than 45 days before events occurance. 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: Expiration Date:
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 Permit.
Name: Carl M. Dameron Carl Maurice Dameron Date:_ 1/13/26 _Signature:
SPRCSD 8/7/2017 revised by Planning Division June 2021
rArE
N Cariomi:
Remona ine
— Street closure
Street closures
11th street blocked at Mt. Vernon, Pico and Western
Herrington blocked at 11th, and Baseline
Baseline blocked at Mt. Vernon, Pico, Blackstone, Western, Ramona, Tijuana, Medical Center Dr., Hancock, Wilson, Madison, Pennsylvania, California, and University Pkwy
Wort Virginte
bne Are W m1305
Wen vyge?
Stage
Vendors
Para.at.-aotr
N California S1 N Caifome St N California St N CB
Histado en
Arsoma An N Artroma Are N Aritona Ave l Neolanio nnt
Marmezny
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"I Ave
N Calfornia
He a Vermo: 419
Wiese Line St
Persona for
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Parade route
East on 11'h street from Graciano Gomez parking lot.
North on Herrington
West on Base line
South on University Pkwy
Extravaganza to take place at Arroyo Valley High School and Anne Shirrells Park Department of the Treasury Date:
Internal Revenue Service 05/10/2022
Tax Exempt and Government Entitie Employer ID number:
IRS P.O. Box 2508
Cincinnati, OH 45201 Person to contact:
Name: Customer Service
ID number: 31954
Telephone: 877-829-5500
SAN BERNARDINO BLACK CULTURE Accounting period ending:
FOUNDATION INC May 31
PO BOX 7288 Public charity status:
SAN BERNARDINO, CA 92411-0288 509(a)(2)
Form 990 / 990-EZ/ 990-N required:
Yes
Effective date of exemption:
April 27, 2022
→.. - Contribution deductibility:
Yes
Addendum applies:
No
DLN:
26053519002792
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.
Based on the information you submitted with your application, we approved your request for reinstatement under Revenue Procedure 2014-11. Your effective date of exemption, as listed at the top of this letter, is the postmark date of your application.
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.
Letter 947 (Rev. 2-2020)
Catalog Number 35152P
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,
stephare a. marten
Stephen A. Martin
Director, Exempt Organizations
Rulings and Agreements
Letter 947 (Rev. 2-2020)
Catalog Number 35152P
Department of the Treasury Notice CP299
Internal Revenue Service Notice date
Ogden, UT 84201-0038 May 30.2022
IRS Employer ID number
To contact us Phone 877-829-5500
FAX 855-214-7520
76841.231793.396276.16378 1 AB 0.461 371
SAN BERNARDINO BLACK CULTURE
% GENEVIEVE ECHOLS
PO BOX 7288
SN BERNRONO CA 92411-0288
176841
Message about Form 990-N (e-Postcard)
Your organization may be required to file a Form 990-N
Our records show that your organization may What you must do immediately be required to file an annual electronic notice
(e-Postcard), Form 990-N. If your organization already filed its annual information return (Form 990, 990-PF, or 990-EZ) or e-Postcard, you don't need to do anything right now. You should continue to file a return or e-Postcard every year.
If your organization hasn't filed its annual information return or e-Postcard, it must file as soon as possible.
The annual information return or e-Postcard is due by the 15th day of the fifth month after the close of your tax period. For example, if your tax period ends December 31 and you are filing Form 990-N, your due date is May 15.
Who can file the e-Postcard Form 990-N?
• A tax-exempt organization other than a private foundation or political or foreign organization whose gross receipts are normally $50,000 or less • A Section 509(a)(3) supporting organization of a religious organization whose gross receipts are normally $5,000 or less
All other supporting organizations generally must file Forms 990 or 990-EZ, even if gross receipts are normally $50,000 or less.
To e-file your organization's e-Postcard:
• Go to irs.gov/charities.
• Type 990-N in the search box.
• Click on the link for the Form 990-N.
If we don't hear from you Revocation for not filing an annual information return or e-Postcard • If your organization doesn't file an annual return for three consecutive years, it will result in automatic revocation of its tax-exempt status as of the filing date of the third year the return or e-Postcard is due.
• If your organization's tax-exempt status is revoked and you want to have it reinstated, it must file an exemption application and pay the required user fee. • If your organization had reasonable cause for not meeting its filing requirement, we can consider retroactive reinstatement.
Continued on back...
City of San Bernardino Assigned Activity #
Public Works Department
300 N. D Street (Office Use Only)
San Bernardino San Bernardino, CA 92401 **Right of Way ** (909) 384-7272
[email protected] Permit Application
**
** General Information
Job Address APN/ Location: Base line Ave dust, Ver non to Coitoralad Nearest Cross Streets):
San Bernardino Black History Pande
Purpose of Permit:
Utility (Circle): Cable Electric Telephone Gas Sewer Water Other) 2/7/26
Work Order #:_ Dates of Work:
Times of Work (If Different from Mon - Fri, 8am - 4pm, no Holiday/Wkends): TAm 40 // ak ** 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 ontractor Information (Please Pript):
Company Name and Address: Black Culture
Co. Phone +909-534-0562ontact Name:Cal M. Dame o 1 Contact Ph#:
City of SB Bus Lic # & Exp Date:_ CSLB Lic #, Class & Exp Date:
General Liability Ins Co: GL Policy Exp Date:
Office Use Only: (Do not Write Below This Line)
• Date: ROW Permit # On / Off-Site Permit #
R
City of
San Bernardino
FOUNDED
1, Carl M. Dameron hereby, certify and acknowledge that 1 am aware of the Workers Compensation laws of the State of California and that I currently employees which would be subject to the protection of the Workers Compensation Act. Further that if at any time during the term of the Agreement, any employees are hired, that | will comply with the requirement of the Workers Compensation laws. At that time I will provide evidence of such coverage to the City of San Bernardino in accordance with the terms of the Agreement.
By: Carl Maurice Dameron Date: 1/13/26
(Signature)
Title: Presdient
Company: The Black Culture Foundation
290 North D St, San Bernardino, CA 92401 | P: 909-384-5161 | F: 909-384-5397 | www.SBCity.org
DATE (MM/DD/MY)
ACORD® CERTIFICATE OF LIABILITY INSURANCE
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 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).
CONLACT Genevieve Chandler
Echols Insurance Agency Na. Ext: (909) 874-3763
Rialto, CA 92377 INSURERS) AFFORDING COVERAGE NAIC I
INSURERA: United States Liability 25895
INSURED INSURER B:
San Bernardino Black Culture Foundation INSURER C :
PO Box 7288 INSURER D:
San Bernardino, CA 92411 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.
INSAT ADDL SUR
LTR TYPE OF INSURANCE POLICY NUMBER LIMITS
INSO WVD.
| COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000
X CLAIMS-MADE OCCUR PREMISES. (Ea occurrence)
MED EXP (Any one person) 5,000
01/28/2026 01/28/27 PERSONAL & ADV INJURY
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
X POLICY PRO- PRODUCTS - COMPIOP AGG
LOC
OTHER:
| COMBINED SINGLE LIMIT
AUTOMOBILE LIABILITY (Ea acadent)
ANY AUTO BODILY INJURY (Por person)
ALL OWNED SCHEDULED BODILY INJURY (Peracadent)| S
AUTOS AUTOS
NON-OWNED ¡PROPERTY DAMAGE i$
HIRED AUTOS AUTOS (Per acaden!)_
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE
EXCESS LIAB CLAIMS-MADE | AGGREGATE
DED RETENTION S
WORKERS COMPENSATION 1. JBETUTE
AND EMPLOYERS LIABILITY YIN
ANY PROPRIETOR PARTNER/EXECUTIVE E.L. EACH ACCIDENT
OFFICER/MEMBER EXCLUDED? NIA
(Mandatory in NH) _E.L. DISEASE - EA EMPLOYEE S
EESCRIPTION OF OPERATIONS DOiOW TEL. DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Black History Parade to be held on 02/07/2026 in San Bernardino CA 92410 - Route from Baseline and Mt Vernon, ending and California St.
The Cily of San Bernardino and its officer, employees, agents and volunteers are named additional insures with respect liabilities out of performmmance of services
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ACCORDANCE WITH THE POLIC PROVISIONS. THEREOF NOTICE WILL BE DELIVERED IN The City of San Bernardino
290 North "D" Street
San Bernardino, CA 92401 i Chandler Genevieve Chandler
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