City Of Michigan City Board Of Public Works And Safety Agenda Request Form (Page 2 of 2) in pdf

ACKNOWLEDGEMENT OF RESPONSIBILITIES:

I understand that if the Board of Public Works and Safety grants my request, the following conditions

and restrictions will apply:

1.) It is my responsibility to provide and maintain proof of liability insurance for this event at my

expense.

2.) It is my responsibility to provide to the Board any additional licenses, permits and documentation

for the event.

3.) I agree to abide by all terms and conditions of the Board’s policy governing walks, runs, parades

or other similar events.

4.) I understand in consideration for approval by the Board for the use of sidewalks/streets for my

event, the undersigned agrees and undertakes to hold the Civil City of Michigan City, Indiana, free

and harmless from any liability loss, damages and expenses including attorney fees, which the Civil

City of Michigan City may suffer or incur as a result of any claims or actions which may be made by

any person, including a participant in said activity, arising out of the approval to use the

sidewalks/streets indicated in Michigan City. I also understand that the closure of streets/sidewalks

does not exempt me or any participant from any State statues or local City ordinances.

5.) In order to ensure public safety during the event barricades are required for a street closure. I

understand it is my responsibility to erect the barricades prior to the event, and to dismantle them

when the event concludes.

6.) Any violations of State law or Local Ordinances (i.e. loud music, public intoxication, or consuming

alcohol on public right away) may result in the immediate termination of my permit by the Michigan

City Police Department.

7.) I understand if my application requires the hiring of off-duty police officers, it is my responsibility to

contract the required number of officers prior to the event.

8.) If a roadway is being closed to vehicular traffic, it is my responsibility to ensure that any property

owners that are affected by the closure are notified, and that ingress and egress to their property is

maintained.

I have read the above acknowledgement of responsibilities and I understand and agree to them. I

also understand that this application may be denied based on any false or incomplete information.

Dated this _________ day of ___________________ 201__

Authorized Signature: ___________________________________________________________

Printed Name:

_____________________________ Phone: ______________________

APPROVED BY THE BOW 07/20/2015

City Of Michigan City Board Of Public Works And Safety Agenda Request Form Page 2