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Event Permit Application Page 1 of 3 EVENT PERMIT APPLICATION FORM Klickitat County Public Works Department 115 W Court St MS 303; Goldendale, Washington 98620 [PHONE REDACTED] – 1-[PHONE REDACTED] – Fax [PHONE REDACTED] Section I: Applicant Contact Name: Organization: Address: City: State: Zip: Section II: Type of Event (Check all the apply): Bicycle Race Running/Walking Event Mixed Event (Bike, Running, etc.) Enclosure Type(s) Event Type(s) Event Course Type(s) Criterium Point to point Time trial Circuit Road event Out and back Stage event Other Mountain bike Multi-sport time trial Totally open event course Partially open event course Totally closed event course Rolling course Protected enclosure Caravan Other Multi-sport road event Car Show Film/Commercial Other (Please describe event below) Will event use agency roads other than Klickitat County Roads? No Yes If yes, have other agencies approved event course? No Yes Expected number of participants: Expected number of spectators: Maximum number of participants on the road at one time: Number of stages participants will be broke into at one time: Maximum number of events on the road at one time: All individuals or groups planning to hold events that serve food and are open to the public are required to get a permit from Klickitat County Health Department. Will you be serving food ? No Yes Have you contacted the Klickitat County Health Department? No Yes Section III: Event Event Name: Event Dates: Event Times: Start: Finish: ---PAGE BREAK--- Event Permit Application Page 2 of 3 Describe event location: (Also, please attach a map of the course.) Sanctioning organization: Name of insurance company: Insurance plan policy number: Adding necessary additional insured. (Klickitat County is to be added as an additional insured on the Certificate of Insurance if Klickitat County roadways are to be used in the event. If roadways belonging to other agencies are used they may request to be added as an additional insured as well.) Section IV: Event Safety/Traffic Control In addition to attaching an Event Traffic Control Plan as described under the Attachment Sections, please complete the following information: Names of certified flaggers: How many total traffic control personnel and course marshals will be available: Name of traffic control personnel and course marshals: Name of chief referee and phone number: Section V: Medical Services Have you contacted the necessary emergency medical service and law enforcement officials of your event? No Yes If yes, whom did you contact: What type of emergency medical services will be available: Section VI: Notification Plan Have you developed a plan for notification of businesses and residents affected by the event course? No Yes Will businesses and residents be notified of bicycle event? No Yes (If yes, please attach a copy of how you will be notifying businesses and residents, i.e. fliers, letters, etc.) Section VII: Additional Required Information and Attachments Please attach the following information to your permit when submitted to Klickitat County Public Works for review and approval. • Attach a copy of insurance certificate for the event with Klickitat County and any other pertinent agencies added as an additional insured. • If more room is necessary to describe event in detail than given above, attach a separate sheet to this permit with your detailed description stating all pertinent information required understanding the event and how it will be controlled. • Evidence that notice of the event has been provided to the public via mass media and to affected property owners. ---PAGE BREAK--- Event Permit Application Page 3 of 3 • Attach a map showing the event course in detail. Mark all important locations including start and finish locations, parking, road closures, traffic controlled intersections, warning signs and other traffic control equipment, etc. • Attach a detailer Traffic Control Plan showing the following information for review and approval of use: o A plan for traffic control for vehicles, pedestrians and spectator safety. o A plan showing the number of, positioning and training of course marshals. o Planned position of flaggers, course officials, marshals, lead cars, support, medical and law enforcement vehicles at the start, during and ending of the event. o Provisions for parking, safe spectator viewing space and rest room facilities. o Types of road signing to be used, their sizes, locations and placement. (If using race event signs provided be the County, they must be picked up and returned to 115 South Golden, Goldendale, WA 98620. A $100.00 fee for each item damaged or not returned will be assessed.) o Communications equipment to be used during the event for flaggers, marshals, etc. (i.e. radio, cell phones, etc.) Please note that all event permits are subject to an application fee of $150.00 if event requires any pre and/or post field work completed by the Klickitat County Public Works Department. The application few is not included in any fees associated with required pre and/or post field work completed by the Klickitat County Public Works Department. Indemnification: The permittee by signing below indemnifies, and saves harmless Klickitat County, for any claim suit, action for injuries, death or other cause of personal injury or property damage arising from the issuance of an event permit, including claims of event participants, pedestrians or other roadway users. Permittee signature Date: Approved: No Yes County Engineer or designee Date: