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12/20/2010 10:03 8133223589 PASCOPAWS PAGE 05/05 <br /> BART IV, AEQVIZED FACI.LI'igS ANA U <br /> Who is your liability carrier for this event? IOW ELL 5 <br /> Attach proof of liability insurance In the amount of One Million Dollars ($1,000,000.00), or Two <br /> Million Dollars (52,000,000.00) if the event will include the consumption of alcoholic beverages <br /> All policies shall nume the City o Ze k Allis as an additional insured for the event. <br /> N s VP.AN c.E c ©v Eft- vin <br /> I/we agree to obtain and maintain the required liability insurance and to secure all necessary <br /> local, state and federal permits and to comply with all terms and conditions applicable to the <br /> conduct of special events, as set forth in Ordinance No. 2005- , as <br /> amended. <br /> Z/we certify that the information contained in this application is true and accurate to the best of <br /> my /our knowledge. As applicant for the event, I/we agree to release and hold harmless the City <br /> of Zepbyrhills from liability of any kind for any and all damages arising out of any loss or <br /> injury resulting from the conduct of this event. This release includes a release for any and all <br /> losses or injury arising while conducting an event using City of Zephyrhills facilides or <br /> property and for any and *Mosses or injury to persons attending this special event. <br /> 1/we certify that individuals will not be barred from participation in this event due to race, <br /> creed, color, national on : ' , sex, age, or physical impairment. • <br /> ,41 By: 1 AngrAbo w Date: NEC.. 2—E 2- / 0 <br /> Title: i <br /> Printed Name: bik V AYES <br /> 5 <br />