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Home My WebLink AboutCascade Classic @ LPR ApplicationKittitas County, Washington BOARD of COUNTY COMMISSIONERS EVENT APPLICATION Thank you for your interest in holding a special event in Kittitas County. Please complete and return this application along with any other materials to the Kittitas County Board of Commissioners at least 60 days prior to the day upon the event is scheduled. Any misrepresentation in the application materials or deviation from the final agreed upon route and/or method of operation described may result in the immediate revocation of an issued permit. Specifics outlining Event Permits can be viewed atht!V:J/www.co.kittitas.wa.usjbocjcoun!ycode/titleO5.asj2 Event Information Name of event: ' easto�� L Date(s) of event: r Hours of Description of the Has this event taken place before? Ye, No Dates.----- Estimated �b�t : X31 2G1� Estimated attendance: IS -0 1B How is your event being publicized? L Tlr"i CL- i 1 Please attach any flyers, posters, etc. with your application submission. Contact Information RI=CEIVE MAY 117 2019 Name of the organizer/ contact person: J,(, lfl tL V4A 'J TT� 1A.1 1st — 2nd— 3rd— .L i I !TAS COUNTY BOARD OF COMMISSIUN" Address 9 Ci sx / ��. O I. Phone number(s):4M-2.,si D 1 4 ! Email address: � c Date of birth of applicant: " t C---'� -11 KITTITAS COUNTY COURTHOUSE 205 WEST 5's , SUITE 108 • ELLENSBURG, WA 98926 (509) 962-7508 • FAX(509)962-7679 www.co,kittitas wa us If the application is made on behalf of a partnership, please submit full names with their residence and post office address for a period of six months prior to the date of application together with the location of principal office or place of business of such corporation. . Emergency contact name(s) and phone number(s) that can be contacted during the event: lir-Vnr � �� r1.711;0-0-49` Name. J Phone Number Name Phone Number WRITTEN PERMISSION TO ENTER EVENT SITE I/ We hereby permit law enforcement and/or County officials to enter the site for which the Event Application has been granted at the time of the event and up to five days prior to the event for the purposes of inspecting and enforcement of County Code and other applicable laws, and pursuant to my agreement and representations made in connection with this Event Application. SWORN STATEMENT OF COMPLIANCE I/ We hereby acknowledge that I/ We have read Kittitas County Code, have familiarized myself with County requirements. I/We agree that either my designated agent or I/we shall be on site at all times and shall be responsible for the operation of the event and for compliance with all legal requirements in connection with this event. I/ We understand that failure to comply with the rules, regulations and conditions set forth in Code may be deemed a gross misdemeanor and thatdru or narcotics violations are crimes under RCW. 0, i : 11. Applicant Name ('rr�t) Applici t-'5xg Applicant Name (Print) Applicant Signature KITTITAS COUNTY COURTHOUSE 205 WEST 5", SUITE 108 - ELLENSBURG, WA 98926 (509) 962-7508 • FAX (509) 962-7679 www.co, k ittitas_wa. us Kittitas County, Washington BOARD of COUNTY COMMISSIONERS Fire Safe and Protection If more than 50 people are expected at your event, you must complete a separate application process which can be obtained through the Kittitas County Fire Marshal's office. You may contact the Fire Marshal's office at 509-962-7000. Will there be a temporary structure erected for the event? Yes 2o If yes, you must attach a drawing including the dimensions. The structure may require an inspection by County staff prior to the event. Public Health/Environmental Health Will there be food served at the event? Yes No If no food will be served at the event then, no permit or application is required. If yes, is the food and beverage that you intend on preparing and serving at the event exempt from permit requirements litW://www.co.k.ittitas.wa.us./health/food.aV? - If yes, please submit an application for exemtativn from permit and proof of food handlers training to the Kittitas County Public Health Department (KCPHD). If yes, and the food or beverage is not considered exempt from permit, then does the person or organization preparing and serving the food have a food service permit, temporary food service permit, or catering permit from KCPHD? 11 -- ` - If yes, please provide a list of foods and beverages that you intend on having prepared and served at the event along with the name and phone number(s) of the permitted person or organization. ��rri�. � �Cr �1i�L� L.LLC- If yes, and the person or organization preparing and serving the ood does not already have a food service permit. - Then a temporary food service permit or catering permit will need to be acquired from KCPHD prior to the event. Please allow at least 2 weeks to complete the food service permitting process. KITTITAS COUNTY COURTHOUSE • 205 WEST 5", SUITE 108 . ELLENSBURG, WA 98926 (509) 962-7508 • FAX (509) 962-7679 www,co.kittitas wa.us Are there permanent or fixed bathroom facilities already available at the location of the event? Yes No If yes, please provide an estimated attendance for the event, a detailed map that identifies the name and address of the physical facility that will provide lavatory facilities for the event, quantity of toilette facilities available for each gender, and the distance from the event that patrons must walk. If no, please provide an estimated attendance for the event, specific information related to the number of portable restrooms that will be provided, the distance from the event that patrons must walk, and a service plan to ensure that sari -cans remain in a sanitary condition. You must include the location of the portable restrooms on a map/ diagram of the event. KITTITAS COUNTY COURTHOUSE • 205 WEST 5h, SUITE 108 ELLENSBURG, WA 98926 (509) 962-7508 • FAX (509) 962-7679 www.co-kittjtas.wa.us 1 Kittitas County, Washington BOARD of COUNTY COMMISSIONERS Law EnforcemenjSecuritylEmergencyMedical Services Will there be security on site during the event? Yes 0 If yes, please provide a complete list of names and contact information for who will be providing the security. Will Emergency Medical Services (EMS) be on site during the event? Yes No If yes, please provide written verification from the providers. Will there be music, sound amplification or any other noise impacts? es No If yes, Kittitas County has a noise ordinance in effect (see County Code for details). If your event is scheduled for outside of the allowed time, you must submit a written letter to the Board of County Commissioners requesting a waiver and it must be included with your application materials. Will you have traffic control? es No If yes, please provide documentation on how the traffic control will be addressed. W e- U.-) \1 W)w -e- 2�e �; c� nix-Va v -0kLk►n leer, C' t e'e (-[- yx1 rCXC'� y Will there be off-site parking? d;)No If yes, please provide the location and a parking plan. !Zlpt,)o ` aSco " . Will there be shuttle buses provided for attendees? Yes If yes, provide a map of their route. Will there be alcohol served at the event? r No If yes, a State permit is required from the WA State Liquor Control Board and must submitted with your application materials. KITTITAS COUNTY COURTHOUSE . 205 WEST 5", SUITE 108 • ELLENSBURG, WA 98926 (509) 962-7508 • FAX (509) 962-7679 WWW.Cakittitas.wa.us Kittitas County, Washington BOARD of C OUNTY COMMISSIONERS �Li Y Public Roads Will the event obstruct, interfere or reqyiw,the closure and free use of any public road, street or right-of-way? Yes No ) If yes, please provide a detailed adequate traffic and detour plans at the time of submission of the application. Will there need to be road closure or detour signs posted? Yes No KITTITAS COUNTY COURTHOUSE • 205 WEST 5`h, SUITE 108 , ELLENSBURG, WA 98926 (509) 962-7508 • FAX (509) 962-7679 www.mkit itas_wa.us Kittitas County, Washington BOARD of COUNTY COMMISSIONERS Garbage�Recycling Do you have a plan for garbage and recycling? Yes No A written plan for garbage and recycling must be attached to your application materials. For questions or assistance contact the Kittitas County Solid Waste Department at 509-962-7542. Insurance Have you obtained a Certificate of Insurancedorsements, specifically naming "Kittitas County" as an insured? Yes. No A copy of the Certificate of Insurance amd endorsements must be included with your application materials. Kittitas County must be named as an additional insured in the amount of $1,000,000.00 per occurrence and $2,000,,000.00 aggregate coverage. This insurance must apply first and on a primary non-contributing basis in relation to any other insurance or self-insurance available to Kittitas County. Penal Bond - Bond of Indemnity A $5,000.00 Penal Bond - Bond of Indemnity is required to be deposited with the County Treasurer to save and protect the streets, pavements, bridges, etc. from damage. The deposit or its balance will be returned once the event has been held and the Board of County Commissioners has certified no damage has been done and that the County has not incurred additional expenses Are yousubrnittin,000.00 P Bond - Bond of Indemnity with your Event Application? o If no, you must request a letter in writing to the Board of County Commissioners requesting a waiver to the Penal Bond - Bond of Indemnity and outline the specific reasons why it should not be required of your event. County Filings and Registration Is there a cost to attend the event? Yes No How much are you charging to attend your event? I ��-- CX�-V ;) KITT1TAS COUNTY COURTHOUSE • 205 WEST 5", SUITE 108 - ELLENSBURG, WA 98926 (509) 962-7508 FAX (509) 962-7679 www.co.kjttitas.wa.us 0 ry 0 0 cn � CD mn CD 0 D v c� 0 0 C4 Q =r CD �0 y CDs_ 0co_ CD CD 3 v CD CD 1 0- cr CD -0 CDcn V� "0CD 0 CD CD CD 0 CA �0y 0�o =CD r CD C CD r" <�� CD > -0 QL ��cn CD o �. 0 0 0 0Q Ot 0 cc 0 00i cn I 1 Ici J 1 0 3 0 f � � r � r6 • T O O 3 J 1 ;=p Z >- I . . CD cn cn UD 3 m 0 a) 0 W 07 3 FD(D w co nj o 3 CD 3 IS, 77 :a' (a 3 SL41�& Sportsman's Insurance Agency, Inc. LOST PAIR RANCH, LLC ATTN: RICHARD HOYT P.O. BOX 814 SOUTH CLE ELUM WA 98943-0814 Protecting Gun Owners and Gert Clubs Since 1991 March 20, 2019 RE: General Liability Insurance Certicificate # NGC 2917 Certificate Effective Date: 3/25/2019 As part of NATIONAL SKEET SHOOTING ASSOCIATION & NATIONAL SPORTING CLAYS ASSOCIATION Master Policy Number: GGLO1001 We are pleased to enclose herewith the renewal Declaration Certificate. Please attach this to your insurance booklet previously submitted. Sportsman's Insurance Agency, Inc. is the Managing General Agent for this program. In the event an accident does occur and particularly one with an injury or fatality, it is requested that you IMMEDIATELY telephone our office at 1/800-925-7767 and report the claim. During evenings and weekends, please leave a message on our answering machine. In addition to the procedure outlined in the above paragraph, please be advised that ALL accidents covered under this liability policy must be reported in writing in the back flap of your insurance booklet we have enclosed for your convenience an accident report form for you to keep on hand should an accident occur. You can also find one on our website at www.slai.net, It is requested that you mail or fax a copy of the loss report to our office so that we are aware of all claims and able to track their handling. As always, should you have any questions concerning the enclosed loss report form or procedure to follow, our office is available for assistance. WPQRTANGENERA-L-LIA51LIT-Y1 SUF:APi _PQE$ J�T_c:oy�fi r --M L��fEES FOR X DRi{ RELATED_ INJURIES All General Liability Insurance policies including the Master Policy exclude (DO NOT COVER) injuries sustained by employees in the course of their employment. Who -are employees'' "Trap boys or girls even if they are working for tips only and all full or part time workers It is a violation of the labor law to employ persons under the age of 16 to work around moving machinery Traps are considered moving machinery If you have trap persons or other full or part time people you need to carry Workers Compensation and/or Employer's Liability Insurance. Please contact us if you are interested in Worker's Compensation coverage If you have so called contract labor, 'Hake sure you obtain a Certificate of Worker's Compensation Insurance from the Contracting firm or person before permitting any work to be performed.. We want to work closely with you to provide the best service available today. This is part of the overall insurance package which Sportsman's Insurance Agency, Inc. is proud to provide. Please do not hesitate to contact our office should you have any questions. Sincerely, Leslie Cas nova Enclosures as stated. 1364 North US 1, Suite 503 • Ormond Beach, Florida 32174 800 925-7767 8 386 677-2588 11 Fax: 386 677-3292 ■ www.sial.net Ir -.II !S�;; u F --Z.. . r.11 C-- Il_ 10451 Gulf Boulevard, Treasure Island, Florida 33708-4814 CERTIFICATE OF COVERAGE CERTIFICATE NO: NGC 2917 -01 This document forms a part of Master Commercial General Liability Policy Number GGLO1001 issued to NATIONAL. SKEET SHOOTING ASSOCIATION & NATIONAL. SNORTING CLAYS ASSOCIATION (NSSA-NSCA) ADDITIONAL INSURED/ MEMBERCLUB LOST PAIR RANCH, LLC P.O. BOX 814 SOUTH CLE SLUM VITA 98943-0814 POLICY PERIOD FROM 3/25/2019 TO 3/2512020 12.01 AM Standard Time at the address of the Insured AGENT. Sportsman's Insurance Agency, Inc. 1364 North US 1, Suite 503 Ormond Beach, FL 32174 www.siai.net 1-800-925-7767 Agent Number: SPORTM LI . _OF INS. . NQE General Aggregate Limit (Other than Products -Completed Operations) NONE Products -Completed Operations Aggregate Limit $1,000,000 Personal and Advertising Injury Limit $1,000,000 Each Occurrence Limit $1,000,000 Damage to Premises Rented to You Limit $ 100,000 Any One Premises Medical Expense Limit S 10,000 Any One Person Total Commercial General Liability Premium $590.00 Minimum Earned Commercial General Liability Premium $550 ADIDITIONAL OPTIONAL COVERAGES - I Hired Auto and Non -Owned Auto Liability and/or Liquor Liability Coverage Occurrence Form If"ileckd.betnw arld a premium Is indl at@d. _ Hired / Nonowned Autos only - Per Endorsement form GGL99.003 1001 X - Hired Auto and Non -Owned Auto Liability Selected with a Fully Earned Premium of $185.00 Liquor Liability Coverage - Occurrence Form - $1,000,000 Each Common Cause; $1,000,000 Aggregate - Per Form CGO033 1001 X - Liquor Liability Coverage NOT Selected It is hereby understood and agreed that the above additional optional coverages are excluded and do not apply to any excess liability coverages if excess general l'lablity is purchased. POLICY FORMS ANDEN QRSEMENT$ TT N 1_Q THE T GGL99 001 1001; GGL99.001 E 1001; CL175 0286; C00001 1001; I L0168 0101; IL0021 0498; CG2646 0499; CG2639 0499; NSSAGC1 0402; NSSAGC2 0402; CG2011 0196; IL0017 1198; CG2002 1185; CG2026 1185; CGO033 1001, CGO103 1000; CG3107 0200 & C00057 0999; GGL99.003 1001 OPTIONAL EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE If sal�ctsd_Iow ani �Rtum_I;ndtilid� Excess Liability - Excess General Liability applies separately to the above listed member providing a limit of coverage NOT Selected in excess of the limits of the Master Policy, subject to an annual aggregate limit of Coverage NOT selected X - Excess Coverage NOT Selected March 20, 2019 Date Total Premium, subject to audit $775.00 ',7 h z A thoriz ignature SHOULD THE ABOVE DESCRIBED POLICY BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE MASTER POLICY PROVISIONS FMPNSSAGC 072013 Paqe 1 of 1 CERTIFICATE OF LIABILITY INSURANCE 1 D3/20/2019' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($). AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(lasl 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 cert} cate does not confer rights to the certificate holder in (leu of such endorsemengs). PRODUCER: CONTACT NAME: Leslie Casanova Sportsman's Insurance Agency, Inc. PHONE: 800 925-7767 Ext 111 FAX: 386 677-3292 1364 North US 1, Suite 503 ELLENSBURG, WA 98926 Ormond Beach, FL 32174 E-MAIL ADDRESS: Icasanova@siai.net INSURED: LOST PAIR RANCH, LLC INSURERS AFFORDING COVERAGE INSURER A: T.H.E. INSURANCE COMPANY P.O. BOX 814 SOUTH CLE ELUM WA 98943-0814 INSURER B: INSURER C: COVERAGES �iii5 IS TO CERTIFY 7HA3 711E I'OL IES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTVvIITHSTANOING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER QOCLIMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AfFORDED f3Y THE POLICIES DESCRIBED HEREIN i8 SUBJECT TO ALL THE TERMS, FaiCLU9lON8 ANO CONOrrIONS OF SUCH POUCIFS. LIMITS SHOWN MAY DAVE BEEN RE UCEO QY PAID CLAIMS. INSRPOLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER (MWDD/YYYY) (MWDD/YYYY) LIMITS A GENERAL LIABILITY ED COMMERCIAL GENERAL LIABILITY OCCURRENCE ❑ CLAIMS MADE MASTER POLICY # GGL01001 3/25/2019 3/25/2020 GENERAL AGGREGATE NONE PRODUCTS-COMP/OP AGG $ 1,000,000 PERSONAL & ADV. INJURY $1,000,000 X❑ PREMISEWOPERATIONS CERTIFICATE # EACH OCCURRENCE $1.000.000 (DAMAGE TO PREMISES RENTED TO YOU lAny One Premises $ 100,000 a HIRED AUTO & NON -OWNED AUTO NGC 2917 -01 MED. EXP (Any One Person) $ 10,000 LIQUOR LIABILITY Each Common Cause OCCURRENCE Aggregate EXCESS LIABILITY EACH OCCURRENCE OCCURRENCE ❑ CLAIMS MADE EIDED [:] RETENTION $ AGGREGATE WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ❑ WC STATLI- OTHER TORY LIMITS E.L. EACH ACCIDENT ANY PROPRIETOWPARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? E.L. DISEASE - POLICY LIMIT jM+andffWry in NHI If yqadescr d under 1) Ui'TION OF OPERATIONS below E.L. DISEASE - EA EMPLOYEE DESCRIPTION OF OPERATIONSILOCATIONS/SPECIAL ITEMS — CERTIFICATE HOLDER IS ADDED AS AN ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES BUT ONLY WITH RESPECT TO THE OPERATIONS OF: LOST PAIR RANCH, LLC KITTITAS COUNTY IS ADDED AS ADDITIONAL INSURED ON A PRIMARY/NONCONTRIBUTORY BASIS, BUT ONLY WITH RESPECTS TO THE NAMED INSUREDS OPERATION. LIABILITY COVERAGE IS NOT EXTENDED FOR ANY OTHER ACTIVITIES. rr-P 'IFII`ATF I-Inii 17FR CANCELLATION FMPCO12011 072013 Includes copyrighted material of 1988-2010 ACORD CORPORATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH KITTITAS COUNTY THE POLICY PROVISIONS. 205 W. 5TH, AVE. ELLENSBURG, WA 98926 AUTHORIZED REPRESENTATIVE FMPCO12011 072013 Includes copyrighted material of 1988-2010 ACORD CORPORATION Kittitas County Office Of The Treasurer Amy Cziske, Treasurer _ _..._ 201-9wnt1zAxenme,.%utteIU7 .....x.e,—. Ellensburg, Wa 98926 Phone (509) 962-7535 Fax (509) 933-8212 Cash Suspense Receipt Number: 2019-1804 Date: 05/17/2019 Received From: MANDY BUCHHOLZ DEPUTY CLERK OF THE BOARD Check Amount: $200.00 Cash Amount: $0.00 Other Amount: $0.00 Total Amount: $200.00 Deputy: MANDYR Receipt Type: CHK Template: COMMISSIONER; COMMISSIONERS Comments: SPECIAL EVENT APPLICATION FOR CASCADE CLASSIC @ LPR - SPORTING CLAY EVENT FundCode G1Code 001 1632171 Total Amount: Description SPECIAL EVENTS FEE Kittitas County Treasurer's Office Submitted By: MANDY ROBINSON Amount $200.00 $200.00 (c) 2002 Cashtax All Rights Reserved www.balancedaction.com