Special Events Permit Application

Special Events Permit Application
I. Title, Purpose, and Brief Description of Event:
Title of Event*
Purpose and Brief Description of Event:*
New ApplicationRenewal of ApplicationChange of Application
Refer media or citizen inquires to:*
Primary Contact Number*
Please enter a valid phone number.
Secondary Contact Number*
Please enter a valid phone number.

II. Application Authorization

Attach a written communication from the organization or organizations in whose name the event will be advertised which authorizes you, the applicant, to apply for the special events permit on its or their behalf.
Applicant's Name*

First NameLast Name
Applicant Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Affiliation:*
Primary Phone Number*
Please enter a valid phone number.
Emergency Phone Number*
Please enter a valid phone number.

III. Event Principals
In the next section, please list names, addresses, and telephone numbers of all the principals involved in any way in the proposed event. Include professional event organizations, event promoters, financial underwriters, commercial sponsors, charitable agencies for whose benefit the event is being produced, the organization or organizations 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.
Primary Principal 1 Information
Name*

First NameLast Name
Title*
Organization/Business/Agency/Affiliation*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Primary Phone Number*
Please enter a valid phone number.
Emergency Phone Number*
Please enter a valid phone number.
Functional Responsibility with Regard to the Event:*
YesNo
YesNo
Primary Principal 2 Information
Name

First NameLast Name
Title
Organization/Business/Agency/Affiliation
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Primary Phone Number
Please enter a valid phone number.
Emergency Phone Number
Please enter a valid phone number.
Functional Responsibility with Regard to the Event:
YesNo
YesNo

IV. Requested Components
Anticipated number of participants: Number*.
Anticipated number of spectators: Number*.
Requested Date(s) of Event, from Date to Date* .
Requested hours of operation, fromTime* to Time* .
Setting up beginning on Date* and Time* .
Dismantle complete by Date and Time* .
Describe the number and type of animals to be used in the event:*
Type N/A if not applicable.
Attach a draft of the entry form for participants/spectators, if any.

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V. Insurance
Attach to this application either an insurance policy or a certificate of insurance including the policy number, amount and the provision that the Town is included as an additional insured.

Please note that insurance requirements depend upon the risk level of the event. Also, if your event can be classified as First Amendment expressive activity, insurance requirements can be waived by the Town Council under certain circumstances.
Attach insurance police or certificate of insurance*

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VI. Sanitation
Attach your “Plan for Clean-up Material Preservation.”
- Include number, type and location of trash containers to be provided for the event.
- Indicate who and how many will be responsible for emptying and cleaning up around containers during the event.
- Indicate who and how many will be responsible for cleaning up the event area after the event. All trash, solid waste or other debris must be moved off Island by the organization or individual submitting the application.
- Describe the number, type and location of portable toilets to be provided for the event area after the event.
- Describe the number, type and location of portable toilets to be provided for the event (or permanent toilets to be used for the event).
- Include any other plan you have for ensuring post-event cleanliness and material preservation of city facilities, equipment, premises and streets.
Plan for Clean-up Material Preservation*

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VIII. Availability of Food, Beverages, and/or Entertainment
If there will be music, sound amplification or any other noise impact, please describe. Include the intended hours, the muisc, sound, or noise anticipated.*
Type N/A, if not applicable.
YesNo
If alcoholic beverages are served, describe what system will be used to ensure that alcoholic beverages will be consumed only by those persons 21 years and older*
Type N/A, if not applicable.
If alcoholic beverages are served, describe how, where, when and by whom the alchoholic beverages will be served.*
Type N/A, if not applicable.
If alocholic beverages are served, attach to the application a copy of your permit from the State AlcoholicBeverage Control Board. Alcohol may not be served without a permit.

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If a casino party, a dance, or live entertainment is part of your event, please describe.*
Type N/A, if not applicable.
Please describe all of the activities of your event for which a business license is required.*
Type N/A, if not applicable.
YesNo
If yes, describe sanitation measures, food handling procedures, and the nature of the food (such as pre-packed foods, hot dogs, pre-mixed sodas, unpeeled fruit, raw meats, vegetables, fish, or peeled and cut fruit).*
Type N/A, if not applicable.
Please attach a health permit from the Pender County Department of Health Services, if required for your event.

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If you intend to cook food in the event area, describe your area layout, including fuel or electrical source to be used.*
Type N/A, if not applicable.

IX. Security and Safety Procedures
Describe your proposed procedures for set up, operation, internal security and crowd control.*
If the event is to occur at night, describe how you are going to light the event in order toincrease the safety of participants and spectators coming to and leaving the event.*
Type N/A, if not applicable
If your event includes vehicles or animals, describe the minimum and maximum speeds of the event and the minimum and maximum intervals of space to be maintained between units.*
Type N/A, if not applicable
Attach to this application a copy of your building permit application (or permits) if you are installing any electrical wiring on a temporary or permanent basis and/or if you are building any temporary or permanent structures such as bleachers, scaffolding, a grandstand, reviewing stands, stages or platforms.

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Please note: tents, canopies, membrane structures with sides over 800 square feet require a fire inspection.
YesNo
Attach a copy of your fire department permit or permits to this application if you will use parade floats; an open flame; fireworks or pyrotechnics; vehicle fuel; cooking facilities; enclosures (and tables within those enclosures); tents, air-supported structures, canopies, or any fabric shelters.

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Below list the name, address, and phone numbers of the agency or agencies which will provide first-aid staff and equipment.
Name of Agency
Name of Representative

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
AmbulanceDoctorsNursesParamedicsOther

X. VENDORS OR CONCESSIONAIRES
Describe what vendor or concessionaires you will allow in conjunction with the event and the purpose or purposes of these concessions.
Type N/A, if not applicable
Describe how you intend to regulate, monitor and control the type, number and quality of vendors/concessionaires whom you may permit to operate in conjunction with the event.
Type N/A, if not applicable

XI. MITIGATION OF THE IMPACT ON OTHERS
Describe how you intend to mitigate the impact of the special events on businesses, churches, neighbors, motorists, mass transit users and others. Attach additional sheets, if necessary, entitled “Mitigation of the Impact on Others.”
Type N/A, if not applicable
Optional Attachment - Mitigation of the Impact on Others

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XII. TOWN SERVICES/EQUIPMENT
Describe town services and/or equipment requested for this event. Town barricades, cones, and no-parking signs may be borrowed on an as-available basis. You should plan to pick up and return this equipment. If you or your volunteers cannot pick up and return this equipment, please attach a letter requesting these services and explaining why your organization cannot perform them. This will be reviewed and approved or denied by the special events coordinator.
Type N/A, if not applicable
Request for Town Services

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XIII. Other Pertinent Information
Include any additional information:
Type N/A, if not applicable
XIV. Optional Information
The following information is not required for permit approval. It is requested so that the Town will have data, in the future, of the dollars raised for charities, the estimated age groups of participants and spectators, the fees charged or donations required and the specific public benefits derived from each event.

Estimate percentage of age groups for participants

Rows	Percentage of Participants	Percentage of Spectators
Age 15 years & under
16 to 25 years
26 to 45 years
46 years & older

If there is a fee or donation required as a condition of attendance or participation in this event, please describe the amounts to be collected from various categories or participants or spectators:
Type N/A, if not applicable
Should be Empty:

Special Events Permit Application

I. Title, Purpose, and Brief Description of Event:

II. Application Authorization

III. Event Principals

IV. Requested Components

V. Insurance

VI. Sanitation

VII. Location Map

VIII. Availability of Food, Beverages, and/or Entertainment

IX. Security and Safety Procedures

X. VENDORS OR CONCESSIONAIRES

XI. MITIGATION OF THE IMPACT ON OTHERS

XII. TOWN SERVICES/EQUIPMENT

XIII. Other Pertinent Information

XIV. Optional Information