Fillable Special Events Permit Application (Pittsfield Charter Township)

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Special Events Permit Application (Pittsfield Charter Township)

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Please Complete Reverse Side
ZP Fee $ ___________
Special Events Permit
Application
Pittsfield Charter Township
Department of Utilities & Municipal Services
6201 West Michigan Avenue, Ann Arbor, MI 48108
Phone: (734) 822-3130 Fax: (734) 944-1103
Website: www.pittsfield-mi.gov Email: planning@pittsfield-mi.gov
Special Events Permit Application
Page 1 of 5
(Please Print)
Applicant Name
Street Address
City State Zip Code
Home Telephone No. Cell Phone
Work Telephone No. Email
$100 application fee (must be paid by cash or check when
application is submitted). Fee is non-refundable. Application will
not be processed until payment is received.
Completed Application Form Date:
Obtained all Township approvals Date:
Copy of Applicant’s Driver’s License (or other identification)
Copies of Certificate(s) of Liability Insurance (if applicable)
Copy of Misc. Use of ROW Permit for road closure(s) (if applicable)
Copy of Liquor License (if applicable)
Copy of Temporary Food Establishment Permit (if applicable)
Copy of Map/Diagram of Proposed Site Plan / Set-up / Parking
Obtained Security / Traffic Control / EMS / Fire Safety services,
as required. (Circle all that apply.)
:: FOR OFFICIAL USE ONLY ::
(Please Print)
Name of Organization / Business Contact Person
Street Address City State Zip Code
Email Office No. Fax No. Cell Phone
Organization / Business Sponsoring Event
(Please Print) (Please Print)
Contact Person No. 1 (Primary Contact) Contact Person No. 2 (Secondary Contact)
Telephone No. Cell Phone Telephone No. Cell Phone
Email Email
Contact Person(s) on Day(s) of Event
Received By:
_____________________
(Initials)
Time Stamp :: FOR OFFICIAL USE ::
Type of Event: Map attach
ed:
Yes
No
(Include locations for parking,
food/beverage, booths, tents,
rest areas, stages, first aid, etc.)
Brief Description of Event
(Please Print)
Name of Event Start Date End Date Estimated Attendance
(Include volunteers & participants)
Hours of Event (List hours of each day separately, if multi-day event) Estimated Time for Set-Up Estimated Time for Clean-Up
Location of Event Purpose of Event Property Zoning Classification
/ / / /
Applicant Information
Event Details
SEPA #____-_______
:: FOR OFFICIAL USE ONLY ::
FOOD & BE
VERAGES:
Will food and/or beverages be served?
Provide a copy of completed WCEH Application.
(See information below)
Date Stamp of WCEH Application:
Copy of Temporary Food Permit Application:
(A copy of the Temporary Food Application to be submitted upon approval of
Washtenaw County Environmental Health.)
:: FOR OFFICIAL USE ONLY ::
If alcoholic beverages are being served at this event, a Special
Liquor License must be obtained from the Michigan Liquor
Control Commission (MLCC), through the Department of
Licensing and Regulatory Affairs (LARA).
Website: www.michigan.gov/lara/
MLCC Licensing Division: (866) 813-0011
Email: mlccinfo2@michigan.gov
Please Complete Additional Page
Special Events Permit Application
Page 2 of 5
UTILITY NEEDS: (List items needed)
Will additional electrical supply be required?
SANITATION / RESTROOM FACILITIES:
BOOTHS / TENTS / AWNINGS: PICNIC TABLES / REFUSE BARRELS:
BARRICADES / TRAFFIC CONES / SIGNS:
Are signs township approved?
Township Approval Date:
CLEAN-UP PROCEDURES:
If food is being prepared for this event, a Temporary Food
Establishment Permit must be obtained from the Washtenaw
County Environmental Health Department (WCEH).
Website: www.ewashtenaw.org/government/departments/
environmental_health
WCEH Contact No: (734) 222-3800
Must apply for this permit at least five (5) business days prior to event.
ALCOHOLIC BEVERAGES:
Will alcoholic beverages be served?
Provide a copy of completed MLCC Application.
(See information below)
Date Approved by MLCC:
Special Liquor License No:
(A copy of the Special Liquor License to be submitted upon approval of MLCC,
State Application Form LCC-3511 or Form LCC-146)
LOGISTICS SECTION
Yes
No
Yes
No
HOSPITALITY SECTION
:: FOR OFFICIAL USE ONLY ::
Special Events Permit Application
Page 3 of 5
Please Complete Additional Page
Please provide details of proposed plans for the following items pertaining to your special event.
If more room is needed for explanation, please attached additional sheets, as necessary.
NOTE: Any increase in township staffing (i.e., security, fire, utilities, etc.,) requested and/or required for this event will be billed
to the organization listed on this form. The Applicant shall be responsible for securing any permits or approvals required in
connection with this event, such as parking permits, utility permits, temporary liquor license, road closure permits, etc.
NOTE: All proposed public safety plans are subject to review and modification by the Pittsfield Charter Township Department of Public Safety.
SECURITY: Will security be on-site for event?
If so, for how long?
Will security be armed?
Will security be uniformed or non-uniformed?
If private security, provide contact information:
CROWD CONTROL / FIRE SAFETY:
How will crowd control be maintained?
If indoor event, will occupancy limit be exceeded?
Will FD be required to remain on-site?
If yes
, indicate timeframe FD is needed:
Will a medical standby be required?
Will fire lanes and hydrants be accessible?
Will there be open flames or pyrotechnics? If yes, list items below:
Will this event have a large amount of combustible material?
If yes, what type and amount?
TRAFFIC CONTROL & TRAFFIC FLOW:
Will pedestrian and vehicular traffic be impacted?
How will the event impact pedestrian and vehicular traffic
flow in and around the area?
Who will direct traffic?
ROAD CLOSINGS: List road(s) to be closed:
Date Approved by WCRC:
Permit No./Resolution No:
(A copy of Road Closure Permit to be submitted upon approval of WCRC)
If a public road(s) must be closed for this event, a “Miscellaneous Use of Right-of-
Way Permit” must be obtained from the Washtenaw County Road Commission.
www.wcroads.org/permits/applications.htm General Contact No: (734) 761-1500
Permits Office: (734) 327-6624 Email: wcrc@wcroads.org
PUBLIC SAFETY SECTION
Describe Proposed Event Plans (Briefly explain how the following items will be addressed at this event.)
/
PARKING: How many staff will handle parking?
How many parking spaces will be available?
Where are parking locations?
If on adjacent properties, is approval obtained?
List all property owners who have authorized parking:
Are Parking Permits Required? If yes, are copies
attached? No. of Permits
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Special Events Permit Application
Page 4 of 5
Impact on Adjacent Properties
Briefly explain how the event may impact other pr
operties, businesses, and/or residents:
Location of Live Band/Disc Jockey/Loudspeakers/Equipment
Will music be provided? Yes No
If yes, what type of music?
Live Amplified Recorded Loudspeakers
Other (Explain)
At a special event for which a Professional Services
Contract for police/fire/medical service is required, the
minimum insurance requirements are as follows:
 Workers’ Compensation Insurance with Michigan statutory limits
and Emp
loyer’s Liability Insurance with a minimum limit of
$1,000,000 each accident for any employee.
 Commercial General Liability Insurance with a combined single
lim
it of $1,000,000 each occurrence for bodily injury and property
damage. The policy shall include contractual liability and personal
injury coverage. Pittsfield Charter Township shall be added as
"additional insured" on General Liability Policy with respect to the
services provided under the Professional Services Contract.
 Automobile Liability Insurance covering all owned, hired and non-
owned vehicles with Personal Protection Insurance and Property
Protection Insurance to comply with the provisions of the Michigan
No-Fault Insurance Law, including residual liability insurance with
a minimum combined single limit of $1,000,000 each accident for
bodily injury and property damage.
 Professional Liability Insurance coverage with a minimum of
$1,000,000 each occurrence. Pittsfield Charter Township must
be named as “Additional Insured.”
 Staff Fidelity Bonding
Insurance Requirements
Unless waived by the Township Supervisor, the following liability insurance is required for approval of this Special
Permits Application.
Please provide one (1) copy(ies) of each certificate of insurance with this application. Certificates must name Pittsfield
Charter Township as “additional insured.”
NOTE: Insurance companies, named insureds and policy forms may be subject to the approval of Pittsfield Charter Township,
if requested by the Township Supervisor. Such approval shall not be unreasonably withheld. Insurance policies shall not
contain endorsements or policy conditions which reduce coverage provided to Pittsfield Charter Township. The Applicant shall
be responsible to Pittsfield Charter Township or insurance companies insuring Pittsfield Charter Township for all costs resulting
from both financially unsound insurance companies selected by the Applicant, and their inadequate insurance coverage. The
Applicant shall furnish the Township with satisfactory certificate(s) of insurance or a certified copy of the policy, if requested by
the Township Supervisor.
At a special event that does not require the services of
police/fire/medical personnel, the minimum insurance
requirements are as follows:

Commercial General Liability Insurance with a combined single
lim
it of $1,000,000 each occurrence for bodily injury and property
damage. The policy shall include contractual liability and personal
injury coverage. Pittsfield Charter Township shall be added as
"additional insured" on General Liability Policy with respect to the
services provided under the Professional Services Contract.
Does this event require Police / Fire / Medical Services?
If yes, what type of services will be required?
Police
Fire Medical Other:
I agree to enter into a Professional Services Contract with
the Pittsfield Charter Township Department of Public Safety
for the above-selected services.
Applicant’s Signature Date
Insurance Requirements Waived Yes
No
Township Supervisor Date
Special Events Permit Application
TOWNSHIP APPROVALS (those required for this event)
Director of Department of Public Safety Date
Fire Marshal Date
Director of Utilities & Municipal Services Date
Director of Parks & Recreation Date
Director of Building Department Date
Date
Zoning & Code Enforcement Administrator
Date
Clerk’s Office
Non-Refundable Application Fee:
$50.00
Date Paid Check No. Cash
Permit Issued Yes No
Township Initials Date
Anticipated Cost to Township: $
Pre-Payment by Applicant:
Amount Paid Date
NOTES:
Applicant’s Permit Compliance Agreement
Applicant Responsibilities
Applicant hereby agrees to be liable to Pittsfield Charter Township for any and all damage that may occur to township property(ies), or
injury(ies) to township employees, officers, or agents caused by this event, or by any person attending or seeking to attend the event,
whether or not such damage is the result of negligence, intentional acts, or accident.
Applicant acknowledges that s/he is responsible for contacting the Michigan Liquor Control Commission
(MLCC), the Washtenaw County
Road Commission, the Washtenaw County Environmental Health Department, and any other agency(ies), to secure any and all permits
required from the State of Michigan, Washtenaw County, and/or Pittsfield Charter Township for this special event.
Applicant acknowledges that the filing of this Application authorizes Pittsfield Charter Township employees and/or officials to enter
the
property to determine the accuracy of the submitted information and conditions, before, during and after event activities.
Applicant agrees to be solely responsible for any and all activities associated with this event; and understands that s/he will be billed for any and
all costs incurred by Pittsfield Charter Township for services rendered in connection with this event.
If Applicant is not an individual, the person(s) signing below affirms that s/he is authorized to bind Ap
plicant to the terms of this
Application/Agreement and is authorized to execute this document on behalf of Applicant.
Approval / Denial of Special Events Permit
This Special Events Permit may be revoked for good cause, including, but not limited to acts of vandalism, violence, or rowdiness,
violations of law or local ordinances, or threats to the health, safety, and welfare of Pittsfield Charter Township residents or visitors. The
Special Events Permit may be revoked by the Township Supervisor and/or his/her designee, including the senior on-duty members of the
Police and Fire Divisions of the Department of Public Safety.
This Special Events Permit may be denied to any person, organization, or group that has, at any time prior to the proposed special event,
held, sponsored or hosted a special event that resulted in acts of vandalism, violence, or rowdiness, was held in violation of law or local
ordinances, or posed a threat to the health, safety, and welfare of Pittsfield Charter Township residents or visitors.
Issuance of this Special Events Permit does not allow Applicant to violate an
y state law or local ordinances.
Authorized Signature Title / Position Date
APPROVED DENIED Reason for Denial:
Township Supervisor Date
:: FOR OFFICE USE ONLY ::
Page 5 of 5
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Special Events Permit Application (Pittsfield Charter Township)

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Completed 14 July 2020

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