NYC Special Events Permit Application Form

CITY OF ITHACA SPECIAL EVENT PERMIT APPLICATION

Submit to City Clerk's Office
108 East Green Street, Ithaca, NY 14850
607-274-6570 (telephone)
607-274-6432 (facsimile)
e-mail: clerk@cityofithaca.org

EVENT INFORMATION:

Event Name: Event Date(s):

Type of event (circle one): Festival Parade Run/Walk Block Party Concert

Other (specify):

Anticipated Attendance:

Event Location:

Event hours:

Date: Set-up Time: AM/PM to AM/PM

Date: Event Time: AM/PM to AM/PM

Date: Tear-down Time: AM/PM to AM/PM

Date: Set-up Time: AM/PM to AM/PM

Date: Event Time: AM/PM to AM/PM

Date: Tear-down Time: AM/PM to AM/PM

Date: Set-up Time: AM/PM to AM/PM

Date: Event Time: AM/PM to AM/PM

Date: Tear-down Time: AM/PM to AM/PM

Event Organizer / On-site Contact Person(s):

Phone: Cellular Phone:

E-Mail Address: Fax:

Sponsoring Organization:

Address:

Phone: E-Mail Address:

Accessibility Coordinator:

Phone: Cellular Phone:

E-Mail Address: Fax:

Traffic/Parking Coordinator:

Phone: Cellular Phone:

E-Mail Address: Fax:

Please provide a detailed description of all special attractions such as rides, booths, interactive displays, etc. Attach additional pages if necessary:

Has this event taken place before? Yes No When?

Are there any changes to this event? Yes No

If yes, explain:

Is there musical entertainment or amplified sound related to your event? Yes No

Contact person in charge of sound:

Cell phone number:

Is electricity needed? Yes No If yes, describe:

Event Electrician:

Cell phone number:

Please outline which venues need electricity and at which locations:

Will other power sources such as a generator be used in the event area? Yes No

For what use, and at which location:

Please describe any plans for the use of special lighting, decorations, fireworks, pyrotechnics, or use of open flames:

Will you need to close a street(s) for your event? Yes No

If yes, what street(s):

Time(s):

Does this event involve a moving route of any kind along streets or sidewalks? Yes No

If yes, please describe and attach a map with the proposed route highlighted indicating the direction of travel:

Will your event impact parking in the area? Yes No

If yes, attach a description of the parking impact stating which lots or streets, and what provisions will be made to accommodate people with mobility issues.

Describe your Parking Plan including provisions for keeping vehicles out of restricted areas, and/or Shuttle Bus Routes/Parking:

Have notices about closures or traffic detours been provided to residential/business owners or tenants? Yes No

Explain:

Accessibility: Please describe your accessibility plan (attach more pages if necessary)

Will food be cooked in the event area? Yes No

If yes, specify method (circle one) Gas Electric Charcoal Other (specify)

Will any tents, booths or structures be erected? Yes No

If yes, describe:

Will the event involve the sale or consumption of alcohol? Yes No

If yes, describe:

How will the sale of alcohol be regulated?

How will the site be contained?

Security Plan: Provide contact information, staffing plans, and the responsibilities of private security teams:

Trash plan: Describe the plan for cleanup and removal of waste and garbage during and after the event.

Number of trash receptacles:

Number of dumpsters with lids:

Number of recycling containers:

Portable and/or permanent toilet facilities:

Number of permanent, accessible toilets:

Number of portable toilets:

Total number of accessible toilets for people with disabilities: (10%)

Number of hand washing stations:

OUTDOOR SMOKING REGULATIONS:

Will a “designated smoking area” be desired for this event? Yes No

If yes, provide information as to proposed location for “designated smoking area”, plans for signage, for monitoring the area, and clean-up:

Medical: Please indicate what arrangements have been made for providing first-aid during your event:

Emergency Evacuation Plan: Please describe your plan to evacuate people in case of severe weather or an emergency situation:

INSURANCE:

The Sponsoring Organization hereby agrees to provide the City with a certificate of general liability insurance...

Block parties and similar neighborhood gatherings, motorcades, parades, and public gatherings...

HOLD HARMLESS

The Applicant agrees on behalf of the Sponsoring Organization...

ANTI-DISCRIMINATION/EQUAL OPPORTUNITY OBLIGATIONS.

In accordance with City laws the sponsoring organization will not discriminate...

CERTIFICATION AND OTHER AGREEMENTS

I certify that the information contained in the foregoing application is true and correct...

FOR OFFICIAL USE ONLY

Approval by City Officials: