Fill - Free fillable Form 133 (City of Lebanon) PDF form

CITY OF LEBANON N.H.—Applications & Permits

Lebanon City Manager’s Office:

Physical address: 20 West Park Street

Lebanon, NH 03766

Mailing address: 51 North Park Street

Lebanon, NH 03766

Email: manager@lebanonnh.gov

Phone: 603-448-4220

Lebanon City Hall offices are closed to the public until further notice. All City Department staff will be available to

answer questions via phone or email.

The City of Lebanon continues to accept applications and permits via email, through the mail or dropped into the

green mailbox outside of the entrance to 20 West Park Street. Application and permit information can be found

on our website here:

https://lebanonnh.gov/203/Applications-Permits

All permits issued for the 2020 calendar year will remain in effect at this time, but with the rapidly evolving

circumstances regarding COVID-19, these may be rescinded. You will be notified at the earliest possible time for

you to plan accordingly.

The City of Lebanon is actively engaged with the New Hampshire Department of Health and Human Services

(DHHS) and our local and regional partners with regards to State and local response to the COVID-19 virus.

We encourage all to visit our website for the latest updates and information:

https://lebanonnh.gov/1350/COVID-19

City of Lebanon Licensing Board—Application for License

Fireworks

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 

-

 

        



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 

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

     

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

                   

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                 

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        

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



Checklist:

 



    



 

 

 

-



FIREWORKS

City of Lebanon Licensing Board—Application for License

Fireworks

Page 2 of 2

-



FIREWORKS







 



 



 

 

 

FOR OFFICE USE ONLY

 











MAYOR: 

City of Lebanon

Insurance Requirements

Page 1 of 3

CITY OF LEBANON N.H.

-

                 



                



INSURANCE REQUIREMENTS

I, (please print legibly) , hereinaer referred to as the

LICENSEE, have requested the use of public facilies, hereinaer referred to as LICENSED PREMISES,

owned and operated by the City of Lebanon, hereinaer referred to as the CITY. The LICENSEE

understands that this aachment constutes a part of that permied use.

1. RELEASE FROM PERSONAL LIABILITY

The LICENSEE hereby releases and forever discharges the City, its heirs, agents, and assigns from any

an all liability for any and all damage to property the LICENSEE brings to the LICENSED PREMISES or any

and all bodily injury the LICENSEE, its employees, invitees, agents, or assigns may suer while at the

LICENSED PREMISES. The LICENSEE has aached hereto a cercate evidencing worker’s

compensaon insurance overage for any and all of its employees.

LICENSEE Signature Date

1.1 Opon to Waive Requirement for Worker’s Compensaon Insurance: The

requirement for worker’s compensaon insurance coverage may be waived by the CITY

if the LICENSEE ceres that they will not have any employees working at the LICENSED

PREMISES. It is understood and agreed by the LICENSEE that waiver of the requirement

for worker’s compensaon insurance coverage does NOT, however, relieve the

LICENSEE from providing the CITY with a Cercate of Insurance, or liability for claims of

property damage, or personal injury to volunteers or non-employees that my assist at

the LICENSED PREMISES.

 I, , hereby cerfy that no employees will

be present at the event, and therefore am requesng a Waiver of Worker’s

Compensaon Insurance by the CITY.

Request for Waiver of Worker’s Compensaon Insurance: [ ] Approved [ ] Denied

City Manager Signature Date

2. RELEASE FROM INDEMNIFICATION FROM THIRD PARTY LIABILITY

The LICENSEE hereby releases the CITY from liability for any property damage or personal injury that

any parcipants may suer while at or on the LICENSED PREMISES. The LICENSEE further indemnies

and holds the CITY harmless from and against all claims for such property damage or personal injury

from third persons on the LICENSED PREMISES at the permission of the LICENSEE, including reasonable

aorney’s fees, whether or not such claims result in ligaon.

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signature

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City of Lebanon

Insurance Requirements

Page 2 of 3

2.1 Cercate of Insurance: The LICENSEE understands that it is required to have valid

liability insurance in force to guarantee its promise to pay damages to parcipants

outlined in Secon 2 above.

 Aached to this release is a valid Cercate of Insurance (required to be in the

amount not less than $500,000 per person and $1,000,000 per occurrence and must list

the City of Lebanon as addional insured) evidencing the LICENSEE’S ability to indemnify

any individual who claims or might claim that acons of the LICENSEE caused him or her

damage to property or bodily injury.

 Tenants Users Liability Insurance Policy (TULIP) is available to individuals or clubs

who need coverage for private events. Low cost coverage is obtainable for single-day

events like weddings, pares, reunions, concerts or charity benets. TULIP insurance

will need to be provided prior to any event held on City property by a private group.

(TULIP informaon sheet aached)

LICENSEE Signature Date

2.2 Waiver of requirement for Cercate of Insurance: The requirement for

Cercate of Insurance may be waived by the CITY if the LICENSEE expects to aract

only 25 parcipants or less. It is understood and agreed to by the LICENSEE that waiver

of the requirement for a Cercate of Insurance does NOT waive the requirement for

acceptance of liability outlined in Secons 1 and 2.

 I, , am hereby requesng a waiver

from the requirement to provide a Cercate of Insurance as I do not expect to

aract more than 25 parcipants at any given me during the event.

The LICENSEE further promises that it will return the LICENSED PREMISES to the CITY in a

condion equal to or beer than its condion prior to its use. This includes removal of

any and all equipment which the LICENSEE brings to the LICENSED PREMISES as well as

lier, and also to repair all facilies damaged during the term of the permit.

Request for Waiver of Liability Insurance: [ ] Approved [ ] Denied

City Manager Signature Date

3. LIABILITY FOR DAMAGE TO CITY FACILITIES

Bond for Damage: The LICENSEE posts a bond (or leer of credit or cash deposit received by the CITY

this date) in the amount of $ payable to the CITY to be used by the CITY to

guarantee the promise in Secon 3 above. The bond (leer of credit or cash deposit) shall be in an

amount determined by the City Manager taking into account the intensity of use that the LICENSEE

ancipates for the LICENSED PREMISES. The LICENSEE understands that the CITY may take this bond

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City of Lebanon

Insurance Requirements

Page 3 of 3

(leer of credit or cash deposit) and repair any and all damage, replace any and all equipment

removed, remove any and all lier, or in any other manner expend it in order to return the LICENSED

PREMISES to a condion equal to what it was before the premises permied use.

3.2 Waiver of requirement of bond for damage: The CITY may waive the requirement

for a bond (leer of credit or cash deposit). Waiver of the requirement for a bond

(leer of credit or cash deposit) does not waive the liability of the LICENSEE for damage

to CITY property outlined in Secon 3.

 I, , am hereby requesng a waiver

from the requirement to provide a Bond for Damage based on the informaon

provided in this applicaon and the low intensity of use expected at this event.

Request for Waiver of Bond for Damage: [ ] Approved [ ] Denied

City Manager Signature Date

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Form 133 (City of Lebanon)

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