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CITY OF EDMONDS
APPLICATION — SPECIAL EVENT
Please Mail or Deliver Completed Applications to: Date:
City Clcrk's Office New Application
121 _ 51h Avenne North
Edmonds, Washington 98020 Renewal
THE EVENT
Title: Edmonds Waterfront Sleeband Festival
July 20th, 2017
Date(s) of Event:
Brief Description of Event: This is the first of an annual event our 501 (c)(3) non-profil hope to be sponsoring in Edmonds. With a
-backdrop of Puget Sound and the Olympic Mountains, a large tent will shelter local steelbands and our guest band from Tri-Citles, WA,
in a compact "festival"'performance. This event will be free and open to the public, and will also entertain those enjoying the beach._
Location of Event.. Edmonds Senior Center Parking Lot
Hours, of Operation: From 5:30P.m. AM/PM To 7:30p.m. — AM � PM
Set Up: Day Thursday Date July 20 Time: From 12 noon AM/PM To 4:30P.m. AM/PM
Anticipated Number of Participants 60 and Spectators 150 - 200
Allach samples q1'an enny.1brmpr parricipants, flyers, andpaniphiets.
PRIMARY CONTACT PERSON:
Name:' Gary Gibson Title: Executive Director
Affiliation: ... of Steel Magic Northwest (event sponsor)
Mailing Address: 20104 - 88th Avenue West
Day Phone: 425.776.8946 Evenino Phone.: 425.776.8946
a
EVENT PRINCIPALS:
Please list narnes, addresses, and teleplione numbers of all (lie principals involved in any way in the proposed Special Event. Include
professional event organizers, event promoters, financial underwriters, commercial sponsors, chiritable agencies for whose benefit dir
event is being produced, the organization(g) in whose name the event is being advertised, and all others administratively, financially,
and organizationally involved as principals in the production of the proposed Special Event. Make additional copies as needed to
include all of the principals involved in the proposed Special Event.
1) Name Gary Gibson
Organization/B"ines,q/Agency/Affiliation: Steel Magic Northwest
Mailing Address: 20104 - 88th Avenue West
Day Phone: 425.776.8946 Evening Phone: 425.776,8946
Title and Functional Responsibility with Regard to the Event: Coordinator of event.
Will this person have the authority to cancel or greatly modi fy event plans?
Will this person be present at the event and in charge of the event at all times?
2) Name
Organizatioti/Busiiiess/Ageilcyi'Affiliation:
C,
Mailing Address:
X1 Yes No
X1 Yes No
EVENT PRINCIPALS CONTINUED:
Day Phone:
Title and Functional Responsibility with Regard to the Event:
Evening Phone:
Will this person have the authority to cancel or greatly tnodif�, event plans? 11 Yes
Will this person be present at the event or areas and in charge of the event at all tirnes? n Yes
3) Name
Organization/Business/Agency/Affiliation:
Mailing Address:
Day Phone:
Title and Ftinctional Responsibility with Regard to the Event:
Evening Phone:
D NO
F1 No
Will this person have the authority to cancel or greatly modify event plans? U Yes LJ No
Will this person be present at the event or areas and in charge of the event at all times? I'; Yes El No
LOCATION / MAP:
Check off the items that apply to your event. Submit a to -scale map showing the checked items.
2 If use of City right-of-way is involved, mark the beginning area, the route (with arrows) and finish area, (Permits F and 11 —
see Page 4)
F1 Mark participant parking areas, bus locations, and special passengers. (Permit F — see Page 4)
n Attauh additional maps of t-Ao or three alternative routes.
For relay route event., indicate "hand-off" points and areas of participant equipment impact.
Ej Entertainment, dance, tent, or stage locations (grandstand operators should provide a to -scale detailed drawing (Pern-lits C
and E -- see Page 4), describe music, sound, amplification, and any other noise impact and hours of each: There is no stagin
required for this event. A 30' X 75'tent will be required (set up time approx. 4 hours). There is no amplification required for
this event, except for making announcements-, the music itself will not be amplified.
There is no checkbox for it below, but we thought perhaps a food truck (or at least an ice cream truck) might be on site also.
Alcoholic beverage concession area: Detail containment of the site (Permit A — see Page 4). Describe the system to be used
to ensure that alcohol is consumed by persons 21 or older, and types of liquor.
Non-alcoholic beverage concession area:
n Food concession / cooking areas. (Permit B — see Page 4)
F1 General merchandise concession areas. (Permit D — see Page 4)
0 Location of street banners. (Permit G — see Page 4) Installation Date
Portable toilet facilities. How many?
Removal Date
LOCATION MAP CONTINUED:
E] First Aid facilities: List agency providing staff and equipment
Name of Agency
Representative
# Ambulances/Aid/iMedic Unit Doctors
# Bike Medics First Aid Station
Phone:
# Nurses
Event Organizer's Command Post.
Fireworks /pyrotechnics site. (Permit MI — see Page 4)
Vehicle hiel handling site.
Site of electrical wiring installed specifically for (he event.
C] Trash containers: How many? Type of Container
Location of live animal sites. Describe:
Aircraft landingand/or hot air balloons. (Permits I — see Page 4) Describe:
# Paramedics/EMT
Specify City park use, indicate each park. (Permit J — see Page 4)
F1 Mark water routes on Puget Sound, (Permit K — see Page 4)
F1 If the event is an exhibition, concert or circus, a Pubtic Amusement License is required. (Permit L — see Page 4)
Pony rides must be located in a spot away from crowds and have fencing all the way around the site. A veterinary's
certificate of health for all animals is required.
Inflatable amusement rides must have a Department of Labor & Industries pennit. (Pen -nit N — see page 4)
INSURANCE:
Please check one:
El City Sponsored Event or Department event function.
Ej Co -Sponsored Event. (Please complete the following.)
List staff liaison and department involvement / control of event
City Budget Fund Account Title
Signature of staff liaison
Attach to this application other available insurance (policy name, number, amount) listing the City as an additional
insured:
Community Event.
.Attach to this application either an insurance policy or a certificate of insurance*, including policy number, amount, date
of issue, and the provision that the City is included as an additional insured. The certificate of insurance shall indicate a
minimum of S 1,000,000* single limit per occurrence.
*Acceptability of insurance amount is sub�jcct to approval by the City's Risk Manager, and the form of the certificate of
insurance is subject to approval by the City Attorney.
SANITATION:
Attach your plan for clean up and material preservation. indicate on your Location Map where the trash containers will be. Indicate
who and how many people will be responsible for emptying and cleaning Lip around containers and the site during the event. If there
are animals, who and how many people will be cleaning up after them, include any other details ensuring post -event cleanliness and
material preservation of facilities, equipment, premises and streets:
CITY SERVICES AND EQUIPMENT:
Describe City services and/or equipment requested for this event. Plan to pick up and return equipment; please attach a letter
requesting these services and explain why your organization cannot provide them. This will be reviewed an approved or denied by the
City. (City barricades, cones, and No Parking signs may only be borrowed for Chamber sponsored events on an as available basis.): _
NOTE: Any special arrangements for street closures, barricades, etc. will be made directIv with the Police, Fire., Public Works, and
Parks and Recreation departments by the applicant aftcr the application has been Touted and approved.
Applicant Signature:
PERMITS THAT MAY HE REQUIRED IF APPLICABLE:
Date:
No.
Type of Permit
Contact
A
Liquor Control Banquet Permit
State Liquor Control Board
B
Health Department Food Handlers Permit (425) 339-5260
Snohomish County
C
Public Dance License (425) 775-2525
City Clerk's Office
D
Solicitor / Peddler Permit (425) 775-2525
City Clerk's Office
E
Sound Truck Pen-nit(425) 775-2525
City Clerk's Office
F
Encroachment Permit (425) 771-0220
Engineering Division
G
Street Banner Permit (42 5) 77 1-023 5
Public Works
H
Parade Permit (425) 771-0200
Police Department
I
Aircraft/Helicopter/Balloon Landing Permit (425) 775-2525
City Clerk's Office
i
Park Facility Use Permit (General Permit Form and Specific City Park Use Form)
Parks and Recreation
(425) 7 71-0230
K
Coast Guard Permit for Use of Navigable Waters
U.S. Coast Guard
L
Public Amusement License (425) 775-2525
City Clerk's Office
M
Fireworks — Public Display Permit
Fire Department
N
Inflatable Amusement Rides
Department of Labor & industries
Page 4
V:',WOR-DATA\Special Events\gpecial Event Application Form Revised 09-01-09.doc
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COMMERCIAL GENERAL LIABILITY
CG 88 10 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
COMMERCIAL GENERAL LIABILITY EXTENSION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
INDEX
SUBJECT
PAGE
NON -OWNED AIRCRAFT
2
NON -OWNED WATERCRAFT
2
PROPERTY DAMAGE LIABILITY - ELEVATORS
2
EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage)
2
MEDICAL PAYMENTS EXTENSION
3
EXTENSION OF SUPPLEMENTARY PAYMENTS - COVERAGES A AND B
3
ADDITIONAL INSUREDS - BY CONTRACT, AGREEMENT OR PERMIT
3
PRIMARY AND NON -CONTRIBUTORY- ADDITIONAL INSURED EXTENSION
5
ADDITIONAL INSUREDS - EXTENDED PROTECTION OF YOUR "LIMITS OF INSURANCE"
6
WHO IS AN INSURED - INCIDENTAL MEDICAL ERRORS/MALPRACTICE AND WHO IS AN
INSURED - FELLOW EMPLOYEE EXTENSION - MANAGEMENT EMPLOYEES
6
NEWLY FORMED OR ADDITIONALLY ACQUIRED ENTITIES
7
FAILURE TO DISCLOSE HAZARDS AND PRIOR OCCURRENCES
7
KNOWLEDGE OF OCCURRENCE, OFFENSE, CLAIM OR SUIT
7
LIBERALIZATION CLAUSE
7
BODILY INJURY REDEFINED
7
EXTENDED PROPERTY DAMAGE
8
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US -
8
WHEN REQUIRED IN A CONTRACT OR AGREEMENT WITH YOU
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With respect to coverage afforded by this endorsement, the provisions of the policy apply unless modified by
the endorsement.
A. NON -OWNED AIRCRAFT
Under Paragraph 2. Exclusions of Section I - Coverage A - Bodily Injury And Property Damage Liability,
exclusion g. Aircraft, Auto Or Watercraft does not apply to an aircraft provided:
1. It is not owned by any insured;
2. It is hired, chartered or loaned with a trained paid crew;
3. The pilot in command holds a currently effective certificate, issued by the duly constituted authority of
the United States of America or Canada, designating her or him a commercial or airline pilot; and
4. It is not being used to carry persons or property for a charge.
However, the insurance afforded by this provision does not apply if there is available to the insured other
valid and collectible insurance, whether primary, excess (other than insurance written to apply specifically
in excess of this policy), contingent or on any other basis, that would also apply to the loss covered under
this provision.
B. NON -OWNED WATERCRAFT
Under Paragraph 2. Exclusions of Section I - Coverage A - Bodily Injury And Property Damage Liability,
Subparagraph (2) of exclusion g. Aircraft, Auto Or Watercraft is replaced by the following:
This exclusion does not apply to:
(2) A watercraft you do not own that is:
(a) Less than 52 feet long; and
(b) Not being used to carry persons or property for a charge.
C. PROPERTY DAMAGE LIABILITY - ELEVATORS
I . Under Paragraph 2. Exclusions of Section I - Coverage A - Bodily Injury And Property Damage Liabil-
ity, Subparagraphs (3), (4) and (6) of exclusion j. Damage To Property do not apply if such "property
damage" results from the use of elevators. For the purpose of this provision, elevators do not include
vehicle lifts. Vehicle lifts are lifts or hoists used in automobile service or repair operations.
2. The following is added to Section IV - Commercial General Liability Conditions, Condition 4. Other
Insurance, Paragraph b. Excess Insurance:
The insurance afforded by this provision of this endorsement is excess over any property insurance,
whether primary, excess, contingent or on any other basis.
D. EXTENDED DAMAGE TO PROPERTY RENTED TO YOU (Tenant's Property Damage)
�13
If Damage To Premises Rented To You is not otherwise excluded from this Coverage Part:
1 . Under Paragraph 2. Exclusions of Section I - Coverage A - Bodily Injury and Property Damage Liability:
a. The fourth from the last paragraph of exclusion j. Damage To Property is replaced by the follow-
ing:
Paragraphs (1), (3) and (4) of this exclusion do not apply to "property damage" (other than damage
by fire, lightning, explosion, smoke, or leakage from an automatic fire protection system) to:
(i) Premises rented to you for a period of 7 or fewer consecutive days; or
(ii) Contents that you rent or lease as part of a premises rental or lease agreement for a period of
more than 7 days.
Paragraphs (1), (3) and (4) of this exclusion do not apply to "property damage" to contents of
premises rented to you for a period of 7 or fewer consecutive days.
A separate limit of insurance applies to this coverage as described in Section III - Limits of
Insurance.
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b. The last paragraph of subsection 2. Exclusions is replaced by the following:
Exclusions c. through n. do not apply to damage by fire, lightning, explosion, smoke or leakage
from automatic fire protection systems to premises while rented to you or temporarily occupied by
you with permission of the owner. A separate limit of insurance applies to Damage To Premises
Rented To You as described in Section III - Limits Of Insurance.
2. Paragraph 6. under Section III - Limits Of Insurance is replaced by the following:
6. Subject to Paragraph 5. above, the Damage To Premises Rented To You Limit is the most we will
pay under Coverage A for damages because of "property damage" to:
a. Any one premise:
(1) While rented to you; or
(2) While rented to you or temporarily occupied by you with permission of the owner for
damage by fire, lightning, explosion, smoke or leakage from automatic protection sys-
tems; or
b. Contents that you rent or lease as part of a premises rental or lease agreement.
3. As regards coverage provided by this provision D. EXTENDED DAMAGE TO PROPERTY RENTED TO
YOU (Tenant's Property Damage) - Paragraph 9.a. of Definitions is replaced with the following:
9.a. A contract for a lease of premises. However, that portion of the contract for a lease of premises
that indemnifies any person or organization for damage by fire, lightning, explosion, smoke, or
leakage from automatic fire protection systems to premises while rented to you or temporarily
occupied by you with the permission of the owner, or for damage to contents of such premises
that are included in your premises rental or lease agreement, is not an "insured contract".
E. MEDICAL PAYMENTS EXTENSION
If Coverage C Medical Payments is not otherwise excluded, the Medical Payments provided by this policy
are amended as follows:
Under Paragraph 1. Insuring Agreement of Section I - Coverage C - Medical Payments, Subparagraph
(b) of Paragraph a. is replaced by the following:
(b) The expenses are incurred and reported within three years of the date of the accident; and
F. EXTENSION OF SUPPLEMENTARY PAYMENTS - COVERAGES A AND B
1 . Under Supplementary Payments - Coverages A and B, Paragraph 1.b. is replaced by the following:
b. Up to $3,000 for cost of bail bonds required because of accidents or traffic law violations arising
out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have
to furnish these bonds.
2. Paragraph 1.d. is replaced by the following:
d. All reasonable expenses incurred by the insured at our request to assist us in the investigation or
defense of the claim or "suit", including actual loss of earnings up to $500 a day because of time
off from work.
G. ADDITIONAL INSUREDS - BY CONTRACT, AGREEMENT OR PERMIT
1. Paragraph 2. under Section 11 - Who Is An Insured is amended to include as an insured any person or
organization whom you have agreed to add as an additional insured in a written contract, written
agreement or permit. Such person or organization is an additional insured but only with respect to
liability for "bodily injury", "property damage" or "personal and advertising injury" caused in whole
or in part by:
a. Your acts or omissions, or the acts or omissions of those acting on your behalf, in the performance
of your on going operations for the additional insured that are the subject of the written contract or
written agreement provided that the "bodily injury" or "property damage" occurs, or the "per-
sonal and advertising injury" is committed, subsequent to the signing of such written contract or
written agreement-, or
@ 2013 Liberty Mutual Insurance
CG 88 10 04 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 3 of 8
b. Premises or facilities rented by you or used by you; or
c. The maintenance, operation or use by you of equipment rented or leased to you by such person or
organization; or
d. Operations performed by you or on your behalf for which the state or political subdivision has
issued a permit subject to the following additional provisions:
(1) This insurance does not apply to "bodily injury", "property damage", or "personal and ad-
vertising injury" arising out of the operations performed for the state or political subdivision;
(2) This insurance does not apply to "bodily injury" or "property damage" included within the
"completed operations hazard".
(3) Insurance applies to premises you own, rent, or control but only with respect to the following
hazards:
(a) The existence, maintenance, repair, construction, erection, or removal of advertising
signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees,
hoist away openings, sidewalk vaults, street banners, or decorations and similar expo-
sures; or
(b) The construction, erection, or removal of elevators; or
(c) The ownership, maintenance, or use of any elevators covered by this insurance.
However:
1. The insurance afforded to such additional insured only applies to the extent permitted by law; and
2. If coverage provided to the additional insured is required by a contract or agreement, the insur-
ance afforded to such additional insured will not be broader than that which you are required by
the contract or agreement to provide for such additional insured.
With respect to Paragraph 1.a. above, a person's or organization's status as an additional insured
under this endorsement ends when:
(1) All work, including materials, parts or equipment furnished in connection with such work, on
the project (other than service, maintenance or repairs) to be performed by or on behalf of the
additional insured(s) at the location of the covered operations has been completed; or
(2) That portion of "your work" out of which the injury or damage arises has been put to its
intended use by any person or organization other than another contractor or subcontractor
engaged in performing operations for a principal as a part of the same project.
With respect to Paragraph 1.b. above, a person's or organization's status as an additional insured
under this endorsement ends when their written contract or written agreement with you for such
premises or facilities ends.
With respects to Paragraph Il.c. above, this insurance does not apply to any "occurrence" which takes
place after the equipment rental or lease agreement has expired or you have returned such equipment
to the lessor.
The insurance provided by this endorsement applies only if the written contract or written agreement
is signed prior to the "bodily injury" or "property damage".
We have no duty to defend an additional insured under this endorsement until we receive written
notice of a "suit" by the additional insured as required in Paragraph b. of Condition 2. Duties In the
Event Of Occurrence, Offense, Claim Or Suit under Section IV - Commercial General Liability Condi-
tions.
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2. With respect to the insurance provided by this endorsement, the following are added to Paragraph 2.
Exclusions under Section I - Coverage A - Bodily Injury And Property Damage Liability:
This insurance does not apply to:
a. "Bodily injury" or "property damage" arising from the sole negligence of the additional insured.
b. "Bodily injury" or "property damage" that occurs prior to you commencing operations at the
location where such "bodily injury" or "property damage" occurs.
c. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the render-
ing of, or the failure to render, any professional architectural, engineering or surveying services,
including:
(1) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions,
reports, surveys, field orders, change orders or drawings and specifications; or
(2) Supervisory, inspection, architectural or engineering activities.
This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in
the supervision, hiring, employment, training or monitoring of others by that insured, if the "occur-
rence" which caused the "bodily injury" or "property damage", or the offense which caused the
"personal and advertising injury", involved the rendering of, or the failure to render, any professional
architectural, engineering or surveying services.
d. "Bodily injury" or "property damage" occurring after:
(1) All work, including materials, parts or equipment furnished in connection with such work, on
the project (other than service, maintenance or repairs) to be performed by or on behalf of the
additional insured(s) at the location of the covered operations has been completed; or
(2) That portion of "your work" out of which the injury or damage arises has been put to its
intended use by any person or organization other than another contractor or subcontractor
engaged in performing operations for a principal as a part of the same project.
e. Any person or organization specifically designated as an additional insured for ongoing operations
by a separate ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS endorsement is-
sued by us and made a part of this policy.
3. With respect to the insurance afforded to these additional insureds, the following is added to Section III
- Limits Of Insurance:
If coverage provided to the additional insured is required by a contract or agreement, the most we will
pay on behalf of the additional insured is the amount of insurance:
a. Required by the contract or agreement; or
b. Available under the applicable Limits of Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable Limits of Insurance shown in the Declaratio ns.
H. PRIMARY AND NON-CONTRIBUTORY ADDITIONAL INSURED EXTENSION
This provision applies to any person or organization who qualifies as an additional insured under any form
or endorsement under this policy.
Condition 4. Other Insurance of SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS is amend-
ed as follows:
a. The following is added to Paragraph a. Primary Insurance:
If an additional insured's policy has an Other Insurance provision making its policy excess, and you
have agreed in a written contract or written agreement to provide the additional insured coverage on a
primary and noncontributory basis, this policy shall be primary and we will not seek contribution from
the additional insured's policy for damages we cover.
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b. The following is added to Paragraph b. Excess Insurance:
When a written contract or written agreement, other than a premises lease, facilities rental contract or
agreement, an equipment rental or lease contract or agreement, or permit issued by a state or political
subdivision between you and an additional insured does not require this insurance to be primary or
primary and non-contributory, this insurance is excess over any other insurance for which the addi-
tional insured is designated as a Named Insured.
Regardless of the written agreement between you and an additional insured, this insurance is excess
over any other insurance whether primary, excess, contingent or on any other basis for which the
additional insured has been added as an additional insured on other policies.
1. ADDITIONAL INSUREDS - EXTENDED PROTECTION OF YOUR "LIMITS OF INSURANCE"
This provision applies to any person or organization who qualifies as an additional insured under any form
or endorsement under this policy.
1. The following is added to Condition 2. Duties In The Event Of Occurrence, Offense, Claim or Suit:
An additional insured under this endorsement will as soon as practicable:
a. Give written notice of an "occurrence" or an offense that may result in a claim or "suit" under
this insurance to us;
b. Tender the defense and indemnity of any claim or "suit" to all insurers whom also have
insurance available to the additional insured; and
c. Agree to make available any other insurance which the additional insured has for a loss we
cover under this Coverage Part.
d. We have no duty to defend or indemnify an additional insured under this endorsement until
we receive written notice of a "suit" by the additional insured.
2. The limits of insurance applicable to the additional insured are those specified in a written contract
or written agreement or the limits of insurance as stated in the Declarations of this policy and
defined in Section III - Limits of Insurance of this policy, whichever are less. These limits are
inclusive of and not in addition to the limits of insurance available under this policy.
J. WHO IS AN INSURED -INCIDENTAL MEDICAL ERRORS I MALPRACTICE
WHO IS AN INSURED - FELLOW EMPLOYEE EXTENSION - MANAGEMENT EMPLOYEES
Paragraph 2.a.(1) of Section 11 -Who Is An Insured is replaced with the following:
(1) "Bodily injury" or "personal and advertising injury":
(a) To you, to your partners or members (if you are a partnership or joint venture), to your members (if
you are a limited liability company), to a co -"employee" while in the course of his or her employ-
ment or performing duties related to the conduct of your business, or to your other "volunteer
workers" while performing duties related to the conduct of your business;
(b) To the spouse, child, parent, brother or sister of that co -"employee" or "volunteer worker" as a
consequence of Paragraph (1) (a) above;
(c) For which there is any obligation to share damages with or repay someone else who must pay
damages because of the injury described in Paragraphs (1) (a) or (b) above; or
(d) Arising out of his or her providing or failing to provide professional health care services. However,
if you are not in the business of providing professional health care services or providing profes-
sional health care personnel to others, or if coverage for providing professional health care ser-
vices is not otherwise excluded by separate endorsement, this provision (Paragraph (d)) does not
apply.
Paragraphs (a) and (b) above do not apply to "bodily injury" or "personal and advertising injury" caused by
an "employee" who is acting in a supervisory capacity for you. Supervisory capacity as used herein means
the "employee's" job responsibilities assigned by you, includes the direct supervision of other "employ-
ees" of yours. However, none of these "employees" are insureds for "bodily injury" or "personal and
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CG 88 10 04 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 6 of 8
advertising injury" arising out of their willful conduct, which is defined as the purposeful or willful intent to
cause "bodily injury" or "personal and advertising injury", or caused in whole or in part by their intoxica-
tion by liquor or controlled substances.
The coverage provided by provision J. is excess over any other valid and collectable insurance available to
your "employee".
K. NEWLY FORMED OR ADDITIONALLY ACQUIRED ENTITIES
Paragraph 3. of Section 11 -Who Is An Insured is replaced by the following:
3. Any organization you newly acquire or form and over which you maintain ownership or majority
interest, will qualify as a Named Insured if there is no other similar insurance available to that
organization. However:
a. Coverage under this provision is afforded only until the expiration of the policy period in
which the entity was acquired or formed by you-,
b. Coverage A does not apply to "bodily injury" or "property damage" that occurred before you
acquired or formed the organization; and
c. Coverage B does not apply to "personal and advertising injury" arising out of an offense
committed before you acquired or formed the organization.
d. Records and descriptions of operations must be maintained by the first Named Insured.
No person or organization is an insured with respect to the conduct of any current or past partnership, joint
venture or limited liability company that is not shown as a Named Insured in the Declarations or qualifies
as an insured under this provision.
L. FAILURE TO DISCLOSE HAZARDS AND PRIOR OCCURRENCES
Under Section IV - Commercial General Liability Conditions, the following is added to Condition 6. Repre-
sentations:
Your failure to disclose all hazards or prior "occurrences" existing as of the inception date of the policy
shall not prejudice the coverage afforded by this policy provided such failure to disclose all hazards or
prior "occurrences" is not intentional.
M. KNOWLEDGE OF OCCURRENCE, OFFENSE, CLAIM OR SUIT
Under Section IV - Commercial General Liability Conditions, the following is added to Condition 2. Duties
In The Event of Occurrence, Offense, Claim Or Suit:
Knowledge of an "occurrence", offense, claim or "suit" by an agent, servant or "employee" of any
insured shall not in itself constitute knowledge of the insured unless an insured listed under Paragraph
1. of Section 11 - Who Is An Insured or a person who has been designated by them to receive reports of
,.occurrences", offenses, claims or "suits" shall have received such notice from the agent, servant or
"employee".
N. LIBERALIZATION CLAUSE
If we revise this Commercial General Liability Extension Endorsement to provide more coverage without
additional premium charge, your policy will automatically provide the coverage as of the day the revision is
effective in your state.
0. BODILY INJURY REDEFINED
Under Section V - Definitions, Definition 3. is replaced by the following:
3. "Bodily Injury" means physical injury, sickness or disease sustained by a person. This includes
mental anguish, mental injury, shock, fright or death that results from such physical injury, sick-
ness or disease.
@ 2013 Liberty Mutual Insurance
CG 88 10 04 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 7 of 8
P. EXTENDED PROPERTY DAMAGE
Exclusion a. of COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE LIABILITY is replaced by the
following:
a. Expected Or Intended Injury
"Bodily injury" or "property damage" expected or intended from the standpoint of the insured.
This exclusion does not apply to "bodily injury" or "property damage" resulting from the use of
reasonable force to protect persons or property.
0. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US - WHEN REQUIRED IN A
CONTRACT OR AGREEMENT WITH YOU
Under Section IV - Commercial General Liability Conditions, the following is added to Condition 8. Trans-
fer Of Rights Of Recovery Against Others To Us:
We waive any right of recovery we may have against a person or organization because of payments we
make for injury or damage arising out of your ongoing operations or "your work" done under a
contract with that person or organization and included in the "products -completed operations hazard"
provided:
1. You and that person or organization have agreed in writing in a contract or agreement that you
waive such rights against that person or organization; and
2. The injury or damage occurs subsequent to the execution of the written contract or written agree-
ment.
0 2013 Liberty Mutual Insurance
CG 88 10 04 13 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 8 of 8
a
AC<_,PR"
CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDNYYY)
3/23/2017
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
UUMIAUI
NAME: Elann Bryan
Great Northwest Insurance Brokers, LLC
PHONE, IA
IA/C, No Exl); (206) 550-1906 (Al-C, No):
t-MAIL
ADDRESS: clnna(tt,_znwib.com
PO Box 13266
INSURER(S) AFFORDING COVERAGE
NAIC #
22506 MHrine View Dr S #201
INSURER A: OHIO CAS ENS CO
24074
Des Moines, WA 99199
INSURED
INSURER B:
INSURERC:
,ic Northwest
Steel Mag
INSURER 0:
PO Rox 1222
INSURER E:
INSURER F:
Edmonds WA 99020
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
AUUL
INSO
DUCK
WVD
POLICY NUMBER
(MMIDWY�YY)
(�A76WyWy)
LIMITS
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000�000
CLAIMS -MADE F_x1OCCUR
PREMISES (Ea occurrence)
S 1 -000,()0()
MEO EXP (Any one person)
s 15,000
PERSONAL & ADV INJURY
S I �000,000
A
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BKS57375464
09/19/2016
09/19/2017
'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2.000,000
F� PRO -
POLICY JECT 7 LOC
PRODUCTS - COMPIOP AGG
$ 21000,000
OTHER:
S
AUTOMOBILE
LIABILITY
C;UM5iNtDZ5IN(UiL IMII
(Ea acbrident)
S
BODILY INJURY (Per person)
S
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Per accident)
S
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
(Per accident)
S
S
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE
S
EXCESS LIAB
HCLAIMS-MADE
AGGREGATE
S
IDED I I RETENTION S
S
NORKERS COMPENSATION
kND EMPLOYERS' LIABILITY Y/N
I'StTA"TUTE ER I'-
E.L. EACH ACCIDENT
S
kNY PROPRIETOR/PARTNER/EXECUTIVE
:)FFICER/MEMBER EXCLUDED? F_�
NIA
E.L. DISEASE - EA EMPLOYEE
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yes, describe under
�t ESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
S
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Certificate holder is named as Additional Insured as respects the Named Insured's participation in the Edmonds
Waterfront Steelband Festival on July 20, 2017.
City of Edmonds
121 5th Ave Nt
Edmonds, WA 99020
(;ANUt-.LLA I IVN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
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FIRE PREVENTION
INSPECTION REPORT
Serving Brier, Edmonds, and 12425 Meridian Ave S
SNOHON11SH CO.' OEDMONDS
Mountlake Terrace Everett, WA 98208 0 BRIER
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FIRE Phone (425) 551-1200 0 MOUNTLAKE TERRACE
[I UNINCORPORATED
DISTR T www.FireDistrictl'.org Fax (425) 551-1272
LOCATION: 220 Railroad Avenue 98020
BUSINESS NAME: Sounds Thrifty Shop
MAILING 220 Railroad Avenue, Edmonds, WA 98020
ADDRESS:
PHONE:
4257745555
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Jul
2017
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KEY ACCESS-2:
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HOME PHONE: 4257746022 URRENT
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Serving Brier, Edmonds, and"
12425 Meridian Ave S
SNOHOMISH Co.
Mountlake Terrace
FERE
'Everett, WA 98208
DEDMONDS
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0 M(jUNtLAKE TERRACE
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Fax (425) 551-1272
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LOCATION:
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Annual
BUSINESS NAME:
PHONE:
SCHEDULED
DATE DUE
Sounds Thrifty Shop
4257745555
MAILING
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ADDRESS:
220 Railroad Avenue, Edmonds, WA 98020
BUSINESSOWNER:
HOME PHONE:
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HOME PHONE:
CURRENT _N
KEY ACCESS-2: Halseth, Barbara—
HOME PHONE: 4257746022
CITY YES NO
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INITIAL I PECTION/bA
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1st RE -INSPECTION
2nd RE -INSPECTION
FINAL RE
EXTENSION
-INSPECTION
VIOLATIONS
DATE DUE:
DATE DUE:
PERSON
GRANTED TO:
DATE DUE:
CITED:
PERSON
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CONTACTED:
CONTACTED:
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INSPECTOR:
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DATE:
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3
VIOLATIONS
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PRE -CITATION
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1 15
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LETTER SENT
NUMBER:
4
CODE
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DATE:
SECTION:_
RETURN RECEIPT
--- -----
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LETTER NEEDED b_Y_E`S*_ff 'NO
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S�&ing Brier, Edmonds, and
SNOHb"H6�
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FIRk-.
DISTRIT WWW.'FireDistrictl.org
LOCATION: 2,20 Fb3ilread Avenue 98021).
BUSINESS NAME: $aunds I hriftv Shup
MAILING
ADDRESS: 220 Railmad Avcnuc, Edmandi, WA 081020
BUSINESS OWNER:
EMERGENCY-1:
KEY ACCESS-2:
EMAIL:
PERSON CONTACTED:
NAME OF INSPECTOR:
I lalsclh, Barbara
�-IRE BYS' IIZN48: tKF
12425 Meridian Ave S
Everett, WA 98208
Phone (425) 551-1200
Fax (425) 551-1272
PHONE: 4 2 5 Tf 4 65 r.
HOME PHONE:
HOME PHONE: 422 I'S 7 7 4 f i 0, -) 2
HOME PHONE:
FIRE PREVENTION
INSPECTION REPORT
0 EDMONDS
El BRIER
El MOUNTLAKE TERRACE
[] UNINCORPORATED
FREQUENCY I STATION& SHIF**'
14 17-C
SCHEDULED
f. DATE DUE 1' Jul 2014
[uFIR II, ;S82
CURRENT
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LICENSE 1:1 1:1
INITIAL INSPECTION DATE
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
-4 V ------ —
2
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I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1st RE -INSPECTION
DATE DUE.
2nd RE -INSPECTION
DATE DUE.
EXTEN�ION
GRANTEDTO-
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VIOLATIONS
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PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2
6
2
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DATE:
CODE
SECTION:
5
3
7
3
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RETURN RECEIPT
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DISPOSITION:
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LETTER NEEDED [] YES El NO
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8
FIRE DEPARTMENT COPY
Westfall, John
From: Bjorback, Leif
Sent: Thursday, December 27, 2012 4:36 PIVI
To: Westfall, John; Stevens, Jim
Subject: RE: Thrift Shop Doors 220 Railroad #106
Jim,
I don't see any major building code issues with this scenario. The work will need a building permit. A partial
floor plan would be helpful. Let me know if you have questions.
Leif Biorback
Assistant Building Official
City of Edmonds
(425) 771-0220 x1 380
From: Westfall, John
Sent: Thursday, December 27, 2012 2:12 PM
To: Stevens, Jim; l3jorback, Leif
Subject: RE: Thrift Shop Doors 220 Railroad #106
Thanks, Jim:
That's funny: I can preview your message in Outlook but when I open up the email, this is what I get
below...
What I read is you want to replace exterior double doors at Sounds Thrifty shop in senior center with
single 42" wide door. As I recall, existing doors are glazed storefront type doors kept "unlocked during
business hours".
I'm forwarding you to Leif for further clarification and approval.
Leif & Jim:
For exiting purposes, it is probably a single required exit, yet Building may wish to evaluate the
occupant load of the Thrift store. That space is independent of the exiting system for the rest of the
Senior Center, and keeps different hours than Senior Center operations.
42" should be wide enough to accommodate the occupant load for the Thrift store.
Building Dept will dictate what kind of hardware including locks are approved for it.
You may also need to keep/install DOOR TO REMAIN UNLOCKED DURING BUSINESS HOURS.
Leif ... ?
John Westfall
Edmonds Fire Marshal
----- Original Message -----
From: Stevens, Jim
Sent: Thursday, December 27, 2012 11:56 AM