03/19/1997 ' STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION FORM 650 - 040.65
AINT REQUEST'FOR TEMPORARY CLOSING /SPECIAL USE OF STATE ROAD M PAGE • 1 2/92 OF 2
PAGE I .
INSTRUCTIONS: OBTAIN SIGNATURES OF LOCAL LAW ENFORCEMENT AND CITY /COUNTY OFFICIALS PRIOR TO SUBMITTING TO DEPARTMENT OF
TRANSPORTATION. ATTACH ANY NECESSARY MAPS OR SUPPORTING DOCUMENTS.
NAME OF ORGANIZATION PERSON IN CHARGE DATE
,EX CwS/LIE SPoRrs 1 (, y0n4s 4. z/O3ARr / /7/ ;
ADDRESS OF ORGANIZATION TELEPHONE NUMBER
/00 Ho(-L' '0 Oe/ -' ! 5Q.3-L, &c.4 RAT f- . /9.4 »/97 '/ 7-z�1/ -5 d
TITLE OF EVENT
l .,A RA /OE TR i4 - rxiLa ^-'
DATE OF EVENT STARTING TIME OF EVENT DURATION OF EVENT (APPROX.) ACTUAL CLOSING TIME (INCLUDING SETTING UP BARRIERS. ETC.)
4T. a
5 C I f 1:Da if "1 Z H'OuAS 7:41e3 Am - /d' o-c3 X 0 / -1 t I
PROPOSED ROUTE (INCLUDE STATE ROAD NUMBER. SPECIFIC LOCATION. ETC. - INCLUDE MAPS) 12:. DON) - 5: T.'' oAd. 9 oNil G (YKM t j I
61, Q
CI. C. Fit. A-7 HM S$ r#4 & 7 f, ,
DETOUR ROUTE (INCLUDE ALTERNATE ROUTES - INCLUDE MAPS)
X04a 41.45 E Fo F° 4-17roreg /4"
NAME OF DEPT. RESPONSIBLE FOR TRAFFIC CONTROL. ETC. (CITY POLICE. SHERIFFS DEPT., FLORIDA HWY. PATROL. ETC.) (INCLUDE PRECINCT NO.)
J
rt:,.1/ E coti .-r>' 57✓C '1 FF oFfr7c
SPECIAL CONDITIONS:
a
THIS SECTION IS TO 8ECOMPtETED WHEN PERMITTING SPECIAL USE OF A STATE ROAD FOR FILMING.
LICENSED PYROTECHNIC•OPERATQR LICENSE NO.
APPROVAL OF LOCAL FIRE DEPARTMENT
LIABILITY INSURANCE CARRIER POLICY EFFECTIVE DATE
COVERAGE AMOUNT (51.000,000 MINIMUM)
LENGTH OF COVERAGE DAYS
FEDERAL AVIATION ADMINISTRATION APPROVAL FOR LOW FLYING FILMING
ADDITIONAL LIABILITY INSURANCE AMOUNT (55,000,000 MINIMUM) .
TYPED NAME AND TITLE (INCLUDE BADGE NO. IF APPROPRIATE) SIGNATURE OF CHIEF OF LAW ENFORCEMENT AGENCY DATE SIGNED
- .........4.
TYPED NAME AND TITLE OF CITY /COUNTY OFFICIAL 4 SIGNATURE OF CITY/ •UN FFICIAL DATE SIGNED
■
(SEAL) 3 1 /1 1q/
ATTEST: DANNY L . • .: • ; ;� A •
'•`'r •1 %I'`✓
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' ' ` `6':.
AUTHORITIES: CHAPTEDER' • 7 '
.- ID • '•. • NISTRATIVE CODE: RULES OF THE DEPARTMENT OF TRANSPORTATION - TEMPORARY
CLOSING AND SPECIAL USE OF STATE ROADS. SECTIONS 337.406(1), 496.06 AND 316.008, FLORIDA STATUTES. S21 -537
APPROVED • 0 .•'r'
FORM 850. 040 -65
- • , MAINT - 02/92
•
PAGE 2OF2
•
The Permittee, shall indemnify, defend, and hold harmless the Department and all of its officers, agents and employees
from any claim, loss, damage, cost, charge or expense arising out of any acts, actions, neglect or omission by
the Permittee, its agents, employees, or subcontractors during the performance of the Contract, whether direct or
indirect, and whether to any person or property to which the Department or said parties may be subject, except
that neither the Permittee nor any of its subcontractors will be liable under this Article for damages arising out
of the injury or damage to persons or property directly caused or resulting from the SOLE negligence of the Department
or any of its officers, agents or employees.
Contractor's obligation to indemnify, defend, and pay for the defense or at the Department's option, to participate
and associate with the Department in the defense and trial of any damage claim or suit and any related settlement
negotiations, shall be triggered by the Department's notice of claim for indemnification to Contractor. Contractor's
inability to evaluate liability or its evaluation of liability shall not excuse Contractor's duty to defend and indemnify
within seven days after such notice by the Department is given by registered mail. Only an adjudication or judgment
after highest appeal is exhausted specifically finding the Department SOLELY negligent shall excuse performance
of this provision by Contractor. Contractor shall pay all costs and fees related to this obligation and its enforcement
by the Department. Department's failure to notify Contractor of a claim shall not release Contractor of the above
duty to defend.
It is understood and agreed that the rights and privileges herein set out are granted only to the extent of the
State's right, title and interest in the land to be entered upon and used by the Permittee, and the Permittee
will, at all times, assume all risk of and indemnify, defend, and save harmless the State of Florida and the Department
from and against any and all loss, damage, cost or expense arising in any mariner on account of the exercise
or attempted exercises by said Permittee of the aforesaid rights and privileges.
•
During the event, all safety regulations of the Department shall be observed and the holder must take measures,
including placing and display of safety devices, that may be necessary in order to safely conduct the public
through the project area in accordance with the Federal Manual on Uniform Traffic Control Devices (MUTCD),
as amended, and the Department's latest Roadway and Traffic Design standards.
In case of non - compliance with the Department's requirements in effect as of the approved date of this permit,
this permit is void and the facility will have to be brought into compliance or removed from the R/W at no
cost to the Department.
Submitted by: Gh'CG4i31 ✓e' .S/" r5 11,e tie1rr1d1 Place Corporate Seal -
Permittee
4
Signat a and Title Attested
Department of Transportation Approval: This Request is Hereby Approved
Recommended for approval Title Date
Approved by: - Date •
District Secretary or Designee
DISTRIBUTION: Original - Permittee
1st copy - District Maintenance Office
2nd copy - Leta/ Maintenance Engineer ®RECYCLED PAPER
Florida r' „ F'r -�
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ISSUE DATE (MM/DD
MCOI:iE. ERTIFIC TE �F' IN $URAN 04 n 03/12/97
, DUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
ii OF DAYTONA BEACH POLICIES BELOW.
0 . BOX 70 COMPANIES AFFORDING COVERAGE
YTONA BEACH FL 32115 -0070
COMPANY A CIGNA SPORTS & LEISURE
LETTER
COMPANY B
JRED LETTER
CLUSIVE SPORTS COMPANY C
RKETING, INC • LETTER
(
60 HOLLAND DRIVE • COMPANY D
ITE 3 —L LtIItR
CA RATON, FL 33487 COMPANY E
LETTER •
THIS IS TO CERTIFY THAT THE )YERAGES
INDICATED_ E MAY BE SSUED OR POLICIES TERM RAN CONDITION AF D BY THE P DESC HERE N S UBJECT TO ALL THE H ERMS, S
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
POLICY EFFECTIVE POLICY EXPIRATION
TYPE OF INSURANCE POUCY NUMBER UMITS
DATE (MM/DD/YY) DATE (MM/DD/YY)
GENERAL UABIUTY B I NDE R2 4 7 8 8 03/01/97 0 3/ 01 / 9 8 GENERAL AGGREGATE $ 1,000,00o
C OMMERCIAL GENERAL LIABILITY PRODUCTS- COMP/OP AGG. $ 1,000,00 •
� LAIMS MADE I X (OCCUR. PERSONAL & ADV. INJURY $ 1,000,00 $
OWNERS & CONTRACTORS PROT. EACH OCCURRENCE $ 1,000,001
FIRE DAMAGE (Any one fire) S
MED.EXP. (Any one person) $
AUTOMOBILE UABIUTY COMBINED SINGLE
ANY AUTO LIMIT $
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS BODILY INJURY
NON -OWNED AUTOS (Per accident $
GARAGE UABIUTY
PROPERTY DAMAGE
EXCESS LIABIUTY EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION I STATUTORY UMITS
EACH ACCIDENT $
AND -
DISEASE - POLICY LIMIT $
EMPLOYERS' UABIUTY
DISEASE -EACH EMPLOYEE $
OTHER
;ESCRIPTION OF OPERAT IONS /LOCATIONSNEHICLES/SPECIAL ITEMS
ERTIFICATE HOLDER LISTED AS ADDT'L INSD IN RESPECTS TO GENERAL LIABILITY
:ARATHON, FLORIDA — OCTOBER 4 -5, 1997
CERTIFICATE HOLDEAAI`CCIaa:A3lrlhl ... .
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MONROE COUNTY MAIL '1() DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
3583 S . ROOSEVELT BLVD LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
KEY WEST FL 33040 LIABI F ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. -)
AUTH IZE REPRE TATIVE r .r
ACORD 2$S (7190) 0 ATION t 990
HOLD HARMLESS AGREEMENT ,
This agreement entered into by and between MONROE COUNTY, FLORIDA, a
political subdivision of the State of Florida hereinafter "COUNTY" and
0XCt - j. va SPAN - rS /mo4.Kerr''"1 j ,Z - ,, -L,
whose address is - - 0 b-t -.4" p , v 3pc/1 RA, ro•-• ', 33 V87
hereinafter "EVENT SPONSORED;" '
WITN ESSETH:
That for and in consideration of the understandings hereinafter set forth the
parties do agree and covenant as follows:
1. That in and for the consideration of permission to use certain public reads
or other public property. more particularly described as follows: of 14-k
._.z., 58 - !o l 4. oi., u, f .ca 4 ? _ r v dP �__. nVo�.+c even M 1
for the purpose of conducting a TA # ItvN - i( �a� -
event, more particularly described as ollows: ""'"J
on the' day of �75f4.
1997 from 7:e AM until /4:0 •SM , the EVENT SPONSOR does herel_y
agree to indemnify the COUNTY in toto for any and all claims or liabilities :hat
may arise out of the above described event.
2. That, in addition to indemnification described in Paragraph One, the EVENT
SPONSOR does hereby agree to hold the COUNTY harmless in all respects
concerning the event described in Paragraph One and will defend any and all
causes of action or claims and will, further, pay the cost of any attorney's f!es
incurred by the COUNTY arising out of the event described in Paragraph One.
MON'OE OUNTY, FLORIDA
B 7 '
gXLLvI� yr SP 0A--71 /.1t871
(Organization) County Administrator
J
By: .
of the above and d authorized
to execute this agreement.
State of Florida
County of Monroe
SUBSCRIBED AND SWORN to
(or affirmed) before me on .15
.,,,�tc-IY"P -17 _(date) by — TO 1.-% 7. 'T -
(name of affiani.). He /she is personally known to me or has
p iced (type of identification) as identification
No a Public' -
r
9 d ZL9E S6Z SOS 1NIVW OVA Jll0 BOdNON WOdd Wd11 :Z1 L661 -51 -1
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
REQUEST FOR USE OF COUNTY PROPERTY
Instructions: Fill in all information where applicable. If not applicable, put
Y appropriate N/A b a ro riate item. Refer to item by number if additional sheet is
necessary to provide further information. (Please type or print.)
1. Name, address & telephone number of organization:
excc.'Sivs SPott,TS MAAKE 6 lobo / / S ( 40c4 "A IDA), i 3 3V . 1
2. Specific County property and /or specific part of requested area for use: c'e"' 1
v. s
/ I (met 50 -(01) + 4c.9 Sokorm o f n4A4n ,/o,.,
CAA 3. Requested date(s) and start /finish time . _' ( 1 :sv AA EAG/N .0 `
0o c '^ ^-% ��
4. Backup Date(s): oc'r. / f / 9 12 ooi� - Q _ in‘
5. Name & brief description of event: P'JtA' 61'4114' 1 '.° 'TS,S 66746 .9 ImA7v646.1 # /tuna
6. Expected number of participants /spectators: A o0
7. Plans for alcohol consumption /sales: NpNE
8. Plans and methods for fund raising: Ca - - , 0OA Te 5PofC+t•'rMA'- / f 64 fr
9. Clean up provisions, assurances and state if any improvements are to be .
made to facility: o,SM wig C(-0254" - ,ip Act /to_f
10. Coordination with: a) Sheriff's Department: r%'AOr 40 ‘ 1 6-'71Y -,3731A Gt-ti7?w(A
b) Security: ND'"E
c) Public Works: t E 7 V L 7V - .Mo.'4.
1 1 . Previous history of holding similar events: PAST" 5/X ke :44- fr"
12. Name, address & lr o telephone number f organization's / contact person:
TM ,'iA S A. Zi �'1.o,c,r" f _ 04• It., 3 -4, / t iury , F L •
. T,' v1/- ?B , at i- fy�- 38ps FAX ' 3 3'/3' 7
13. Does the organization currently have liability insurance? >S
FOR COUNTY USE
Scheduled date:
Approved: YES_ NO f3Y:
Insurance /Hold H armless Requirements: - "
FEES:
�_� � ZZ �-Y� c a_ � kl ��_ • ��, � Le , ';
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al
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