HomeMy WebLinkAboutSpecial Event App & ReceiptKiuitas County, Washington
BOARD or COUNTY COMMISSIONERS
EVENT APPLICATION
Th*ry you for your interest in holding a special event in Kittitas County. Please
complete and return this application along with any other materials to ihe Kittitas
Cguryy 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 at http: / /www.co.kittitas.wa.us/boc/countycode/ titleOS.asp
Event Information
Name of event: 2021 WA State Soortino Cl avs Chamoionshio
Date(s) of event July 1,2.3.4 2021
Hours of operation:7:00am -6:00om
Description of the Com S tou sanctioned
bv Washinoton State Soortino Cla vs Assosiation
Has this event taken place before? {" No Dates: Septeqber 20, 2018
Estimated 1 time
How is your event being publicized?Online tkbuoh F a . WSCA.
NSCA- Score Chaser
'i:"{lir:':1\ i 't'':i! t'
Please attach any flyers, posters, etc. with your application submission
Contact Information llAR '21 ?CI?1
Name of the organizerfcontact person: RiOhard Hoyt ,, ,,,,,
Address: PO Box 814 South Cle Elum.wA 98943 ! ili,r',lii;"
., . r:-._-,
,j i-',",;rl!.r.'
Phone number(s): 425-281-0749
Email address: rich@hardline-construction.com
Date of birth of applicant: 1 1 l8l 197 4
KITTITAS C0I,JNTY CoURTH0USE ' zos wrsr $, SUITE IO8 ELLENSBURG, wA 98926
(509) 962-7508 FAX (509) 962-7679
www.co. kittitas.wa.us
If the application is made on behalf of a parbrership, 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:
509-304-50n2
Name
Donna And n
Phone Number
4:6.719:5314
Name Phone Number
WRITTEN PERMISSION TO ENTER EVENT SITE
I/We hereby permit law enforcement alrd./ 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 COMPTIANCE
l/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 l/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,and conditions set
forth in Code may be deemed a gross misdemeanor and that narcotics
violations are crimes under RCW
ApplicantName (Print)Applicant
Applicant Name (Print)Applicant Signature
KITnrAscouNTycouRTHousE. zoswnsrS, strITE 108 ELLENSBURG,wA98926
(509) 962-7508 FAX (509) 962-7679
www.cokittitas.wa.us
Kittitas County, Washington
BOARD or COUNTY COMMISSIONERS
Fire Safefy and Protection
If more than 50 people are expected atyour 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 y6
If yes, you must attach a drawing including the dimensions. The structure may
require an inspection by County st#f prior to the event.
Public HealthlEnvironmental Health
Will there be food served at the event? Yrl 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 http : / / lvww. co.kittitas.wa. us / health / food. asp?
- If yes, please submit an application for exemption 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 permi! then does the
person or organization preparing and serving the food have a food service permit,
temporary food service permif or catering permit from KCPHD?
- 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.
If yes, and the person or organization preparing and serving the food does ngt 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. zos wesr S, SUITE 108 ELI-ENsBURG, wA 98926
(s09) 962-7508 FAX (50e) 962-7679
www,co.kittitas.waus
Are there permanent or fixed bathroom facilities already available at the location of
the event?
Yes y6
If yes, please provide an estimated attendance for the event, a detailed map that
identifies the name and address of the physical facilify that will provide lavatory
facilities for the event, quantrty 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 sani-cans remain in
a sanitary condition. You must include the location of the portable restrooms on a
map/ diagram of the event.
KIrrIrAs couNrY ""u*td#i?r,r33i Ytfllrir",ff ]ro;,; ELLENSBUR*' wA e8e26
www.co. kittitas.waus
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Kittitas County, Washington
BOARD oF COLINTY COMMIS SIONERS
Will there be securit5r on site during the event? Yes fld
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? J
If yes, please provide written verificationfrom the providers.
Will there be music, sound amplification or any other noise impacts? V" 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? V" No
If yes, please provide documentatiqn on how the trafficcontrol will be addressed."Thi-rZ.u\r\ ^ ba vc{,\rn{€zt's direa-{ivrar pa-r\4n3 *o "e*i=*,*rg"c-mer+.art Ll a,L Lzbs ltttr". 9s f E-'4va9S
Wilt there be off-site parking? Vg No \'
If yes, please provide the location and a parking plan.
lze nva4p
Will there be shuttle buses provided for attendees? Yes t6
If yes, provide a map of their route.
Will there be alcohol served at the event? Vg No
If yes, a State permit is required from the WA State Liquor Control Board and must
submitted with your application materials.
KITTTTAS couNTycouRTgousE. 20s wEsrS, sutte 108 ELLENsBURG,wA98926
(s09)962-7508 FeX609)962-7679
www.co. kittitas.wa.us
Kittitas County, Washington
BOARD oF COUNTY COMMISSIONERS
Public Roads
WiIl the event obstruct, interfere or require the closure and free use of any public
road, street or right-of-way? Yes 116
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 #
KITTITAS couNTycouRTuousE. zoswnstS, SUITE 108 ELLENsBURc,wA98926
(509)962-7s08 F/.X(silr9eZ-76't9
www.co.kittitas.wa.us
Kittitas County, Washington
BOARD or COUNTY COMMISSIONERS
Garbage/Itecycling
Do you have a plan for garbage and recycling? V" 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 509-9 62-7 542.
Insurance
Have you obtained a Certificate of Insurance and endorsements, specifically
naming "Kittitas Count5l" as an insured? V 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 $1,00O000.00 per occurrence and $2,000000.00 assresate coverase. This
insurance must apply fir3t and on a primary non-contributih! bEsis in relation to any
other insurance or seU-insurance available to Kittitas County.
Penal Bond - Bond of Indemnifv
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 you submitting a $5,000.00 Penal Bond - Bond of Indemnity with your EventAppiication? "'{rg' U6
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 und 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? Vt No
How much are you charging to attend your event? $400.00
KITTITAS cotrNTy couRTuousE . zos wssr $, surre 108 ELI-ENSBURG, wA 98926
(509) 962-7508 FAX (s09) 962-76',r9
www.co,kittitas.wa.us
Kittitas County Public Health DepartmentEi(VIRONMENTAL l.lgAl"TH - 5tF7 N Nanum St, Suirn r02 Ellensburg, WA9!.{n6. (r'JP,gtrf-?|)tsFood llstabIishrnentPOST IN A CONSPICUOUS PLACE IIOR PUBLIC VTEW'THIS LICENSE IS NOT TRANSFEMBLETNrne of Btrdrere Miners pi*za Co"Sib Addnas 121 E Firsr Sr, CI.E ELUM WA 9892thlcTlpe C,erreral Food Sen,ice - Level l116lr* 2PM - BPMtlseNumbcr FE.2OO00O6ValtdFroau ll/OtnOZOValidlhloutlr rcBt/AmtSenricesfrrr. lut l,l to, r.t.rr (frhgral(illit{t Cor/ntvPublic HealthtoAia.t rdAwatO0prrtrn?ntlrl li*r 6t dhaonmldffa Fqpl eai(dat Ctrrra/
Garbaee &Recvclins Plan
There will be a 20 yard dumpster for garbage and an 8 yard dumpster for recycle.
Several garbage cans will be placed throughout the property. Volunteers will be
assigned to dump/maintain all garbage and recycle during the event.
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@ Washington State
Liquor and Cannabis Board
Washington State Liquor Cannabis Board
BANQUET PERMIT
(Dge-Nq! Authorize Sale of Alcohol)
Document Number: LCB-BP2{ 1605
Name of Organlzation (if applicable):
Lost Pair Ranch
Start Date of Evont:
Jul 03, 2021
Appllcants Name:
Richard Hoyt
Phone Number:
509.304-5002
Event Start Time:
5:00 PM
Applicants ]lome Address:
3900 Pasco Rd Cle Elum WA 98922
Event EndTime:
8:00 PM
Name of Bulldlng or Locatlon:
Shop
Room orArea Held:
outside shop
Number of Event Dayo: 1
Street Addrese of Building or Location:
3900 PASCO RD
Clty
CLE
of Building or Locallon:
ELUM
County of Building or Locatlon:
Kiftitas
Purpose of Occaslon (be speclfic): Banquet after sporling event for awards
Number of Persons to Aftend: 80 Number of Persons Under 2l Years of Age That Wll Attend: 5
Attendees WILL NOT bring their own Alcohol.
Name of Caterer:Address:Phone:
have accepted this pormit subject to followlng condltions:
THE EVENT WLL NOT BE OPEN TO TH.E PUBLIC. No advance sale of tickets will be made to general public and no advertising will
be directed to the general public.
Liquor will not be sold for cash, scrip, tickets or any other manner whatsoever.
This permit is not valid on liquor-licensed premises while the liquor license is suspended.
All liquor served will be purchased in Washington State from an authoriz€d liquor retrailer.
This permit will be conspicuously posted in the banquot area.
Liquor will be served and consumed only in the portion of the Building or Location described,
Liquor will be served only lo members and invited guests who are 21 years of age or older.
Legal hours for service and consumption of liquor are 6:00 a.m to 2:00 a.m daily
The event and the premises for which the permit is issued will be subject to inspection by any liquor control officer or law enforcement
officer.
WAC 314-18-070 statee that no banquet permlttee or employee of a banquet permlttee may knowingly permit.
The service of liquor to or consumption of liquor by any person under 21 years of age at the Banquet Permit event,
Any disorderly conduct to occur at the Banquet Permit event.
The service of liquor to or consumption of liquor by an apparently inloxicated person(s).
could
applicatlon and accepting the Banquet Permit YOU ARE ASSUMING FULL RESPONSIBILW FOR THIS FUNCTION. A
subject the vlolator to criminal prosecutlon, immediate cancellatlon of the permit and render the appllcation/premlses
for future pcrmlts.
making this
This permit is not valid unless signed, dated and posted at the event location.
I am assuming full responsibility for the event and the compliance of the rules
Sign your name to affirm the above conditions:
above.
Dale:3-5-U
LtQ 158 4t12
CERTI FICATE OF LIABI LITY INSURANCE DATE (MM/DD/YYiY)
3t11t2021
THIS
THETHE
ORABETVUEEN
lf SUBROGATION lS WAIVED, sublect
rlght3 b tho certlflcate holder ln lla'u of
to tfie terms and conditions
such endo6ement{s).oolicv(lesl must be endorsed.
$ls eardficate docs not conferTNSURED, the
A statoment onIMPORTANT: lf the c€rtlftcato
the policy, certaln Pollcies maY
ofAODTTIOI{ALlgholderan
endon3ementanrequlre
CONTACT NAME: Leslie Casanova
PHONE: 800 925-7767 Ext 1 11 FAX: 386677-3292
E.MAILADDRESS:
Sportsman's lnsurance AgencY, lnc.
PRODUGER:
FL 32174Ormond Beach,
1364 North US 1, Suite 503
rNsuRER(S) AFFORDING COVERAGE
T.H.E, INSURANCE COMPANYINSURER A:
INSURER B:
INSURER C:
INSURED:
LOST PAIR RANCH, LLC
P.O. BOX 814
SOUTH CLE ELUM WA98943-0814
x
'occuRRENcE f] crarrrs r,nnoe
[l Hneo nuro & NoN-owNED Auro
INSR
LTR
A
3t25120223t25t2021
1PREMISES/OPERATIONS
One
TO
POLICYEFF POLICYEXP
(MM/DD/YYYY) (MM/DD/YYYY)
GENEMLAGGREGATE NONE
PRODUCTS.COMP/OP AGG $ 1,000,000
PERSONAL &ADV. INJURY $ 1,000,000
LIMITSPOLICY NUMBER
MED. EXP
GENERAL LIABILITY
COMMERCIqL GENERAL LIABILIry
MASTER POLICY #
GG101001
CERTIFICATE#
NGC 2917 -03 $ 100,000
$ 10,000
Each Common Cauee
AggregateLIQUOR L]ABILITY
I occunner.rce
EACH OCCURRENCE
AGGREGATE
I excess LrABrLtrY
[occunnence f] cu'tls tueot
f]oro In*rNro*s
I Y['*V0il$. ! ornen
E.L. EACH ACCIDENT
E.L. DISEASE - POLICY LIM]T
E.L. DISEASE. EA EMPLOYEE
WORKERS COMPENSATION AND
EMPLOYERS' LLABILITY
ANy pRopRrEToR/pARTNER/EXEcurvE g
oFF|CER/MEMBER EXCLUDED? Ll
(Mand.tory ln NH)
ff ves. describecl und€r
DESCRIPTION OF OPERATIONS boloil
DESCRIPTION OF OPERATIONS'LOCATIONS/SPECIAL ITEMS - CERTIFICATE HOLDER 13 AODED AS AN ADD]TONAL INSURED '
RESPECT TO THE OPERATIONS OF:
MANAGERS OR LESSORS OF PRESISES BUT ONLY U'ITH
LOST PAIR RANCH, LLC
KITTITAS COUNTY IS ADDED AS ADDITIONAL INSURED ON A PRIMARY/NONCONTRIBUTORY BASIS, BUT ONLY WITH
RESPECTS TO THE NAMED INSUREDS OPERATIONS. LIABILITY COVEMGE IS NOT EXTENDED FOR ANY OTHER
ACTIVITIES
sHouLD ANY OF rHE ABOVE DESCRIBED P,O-Ll!i!!:s- EE CANCEL!F-D-EE|o^EE--IEE
EliFriiftr6ili'oiiE THdREo-F;NonaE WLL BE DELIyERED lN AccoRDANcE wlrH
THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVEfu,(ry
KITTITAS COUNTY
205 W. sTH, AVE.
ELLENSBURG, WA 98926
FMPCOI2011 072013 lncludes copyrighted material of 198&2010 ACORD CORPORAI0N
r -l-t-f--I t{ e t-, R fi\l\tcE
CONlIP, 1.f{Y
10451 Gulf Boulevard, Trcasure lsland, Florida 337064814
CERTIFICATE OF COVERAGE
CERTIFICATE NO: NGC 2917 -03
This document forms a part of Master Commercial General Liabillty Policy Number GGL01001 issued to
NATIONAL SKEET SHOOTING ASSOCIATION & NATIONAL
SPoRTTNG CLAYS ASSOCTATTON (NSSA-NSCA)
ADDITIONAL INSUREDI MEMBER CLUB
LOST PAIR RANCH, LLC
P.O. BOX 814
SOUTH CLE ELUM WA 98943.0814
POLTCY pERtOD FROM 3t25t2021 TO 3t25t2022
12:01 AM Standard Time at the address of the lnsured
AGENT:
Sportsman's lnsurance Agency, lnc.
1364 North US 1, Suite 503
Ormond Beach, FL32174
www.siai.net
1-800-925-7767
Agent Number: SPORTM
GeneralAggregate Limit(Otherthan Products-Completed Operations) NONE
Products-Completed OperationsAggregate Limit $1,000,000
Personal and Advertising lnjury 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 ,1p$00 Aly O!9 Person
Total Commercial General Liability Premium $550.00
Minimum.Eamed Commercial General Liability Premium $550
ADDITIONAL OPTIONAL COVERAGES -
Hired Auto and Non-Owned Auto Liability and/or Liquor Liability Coverage Occurrence Form
Hired / Nonowned Autos only - Per Endorsement form GGLS9.003 1001
X - Hired Auto and Non-Owned Auto Liability Selected wlth a Fully Earned Premium of $185.00
Liquor Liability Coverage - Occunence Form - $1,000,000 Each Common Cause; $1,000,000 Aggregate - Per Form CG0033 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 liabillty coverages if excess general liablity ls purchased.
GG199.001 1001; GG199.001E 1001; C1175 0286; CG0001 1001; 110168 0101; 110021 0498; CG2646 0499; CG2639
0499; NSSAGC1 04A2; NSSAGC2 0402; CG2011 0196; 110017 1198; CG20021185; CG2026 1185; CG0033 1001;
CG0103 1000; CG3107 0200 & CG0057 0999; GG199.003 1001
EXCESS COMME IAL GENERAL
Excess Liability - Excess General Liability applies separatelyto the above listed member providing a limit of Coverage NOT Setected
in excess of the limits of the Master Policy, subject to an annual aggregate limit of Goverage NOT Selected
X - Excess Coverage NOT Selected
Total Premium, subiect to audit $735.00
,/rr*/*o***-March 11,2021
Date V Adthorizedsignature
SHOULD THE ABOVE DESCRIBED POLICY BE CANCELI FD BEFORE THE EXPIRATION DATE THEREOF, NOT]CE WILL BE DELIVERED IN
ACCORDANCE WITH THE MASTER POLICY PROVISIONS.
FMPNSSAGC 072013 Pase 1 of1
Kittitas County OfEce Of The Treasurer
Amy Cziske, Treasultr
2O5 WsihAl,[trur, ilulh lU:
flensburg, Wa 98926
Phone {509} 962-7535 Fax (509) 933-8212
Cash Receipts
Receipt Nurnber':
Received From:
FundCode
001
202t-t723
MANDY BUCHHOLZ DEPUTY CLERK OF THE BOARD
Date:03/24/202t
Check Amount: $200.00
Cash Amount: $0.00
Other Amount: $0.00
Total Arnount: $200.00
Deputy: SMYRA Receipt Type: CHK
Tcrnplatc:
Conrnrents:
csR 202t-r259
SPECIAL EVENT APPLICATION FOR 2O2I WA ST SPORTING CLAYS CI'IAMPIONSI.IIP JULY 1,2,3,4
ClCode
163217 |
Description
SPECIAL EVENTS FEE
Amount
$200.00
$200.00Total Anrount:
Kittitas County Treasurer's Office
Submitted By: SAVANNA MYRA
(c) 2002 Cashtax All Rights Reserved 0312412021 1 1:10:49 SMYRA