Form Center

2. INSTRUCTIONS
   Please click here or call 515-262-9368 to check availability of park shelters and similar public facilities before submitting this application.

   The City of Pleasant Hill would like to thank you for considering our community as a host site for your Special Event. Please submit this application and other required materials to the Pleasant Hill City Clerk at least 60 days prior to the date of the event, with proof of insurance and/or other certificates, permits, and/or licenses listed below if needed at least 30 days prior to the date of the event. All events will be approved by Pleasant Hill City Staff and/or the Pleasant Hill City Council, if a resolution is required. The Special Event Application states which conditions need to be met for the event to be approved.
   
   City approval of a Special Event Application does not preclude responsibility for any additional permits, approvals, or state and federal regulations. The City may cancel the event with notice, impose special guidelines and/or restrictions; included but not limited to: the nature of the proposed event, its attendant circumstances, weather forecasts, the event being deemed hazardous to public safety and/or public or private property.
   
   The City of Pleasant Hill's Special Event Application is necessary for the use of private property, public property and/or park property that requires right-of-way usage or temporary street closures (excluding block parties), parades, runs/walks, fairs/festivals, outdoor concerts/amplified sounds, athletic events, fundraisers, farmer’s markets, fireworks/pyrotechnics, temporary structures (tents, canopies, stages, inflatables). The City of Pleasant Hill will determine whether an event is classified as a Special Event if outside of the description stated above.
   
   REQUIRED, AT MINIMUM, 60 DAYS BEFORE THE EVENT: Completed Special Events Application
   
   REQUIRED 30 DAYS BEFORE THE EVENT:
   1. Proof of insurance noting the City of Pleasant Hill as additional insured for event.
   2. Proof of barricade confirmation, if applicable.
   3. Proof of proper number of volunteers needed to host the event.
   4. Proof of liquor license, if applicable.
   5. All related permits need to be completely filled out and turned in.
4. First Name*
5. Last Name*
7. Address1*
9. Address2
11. City*
12. State*
13. Zip*
15. Email*
16. Phone*
18. EVENT INFORMATION
20. Event Name*
21. Event Date*
23. Event Type*

    1. New event
    2. Returning event
    3. Returning event with modifications
25. Event Location*
27. Pending approval, please call City Hall at 515-262-9368 to check availability of your event location.
29. Event Sponsor/Organization*
31. Event Description*
33. Event Start (Event Setup)/End Time (Tear down Time)*
    Event Start (Event Setup)/End Time (Tear down Time) Start Date

    Event Start (Event Setup)/End Time (Tear down Time) Start Time

    —

    Event Start (Event Setup)/End Time (Tear down Time) End Date

    Event Start (Event Setup)/End Time (Tear down Time) End Time
    **Please include time frame for delivery of amenities such as sanitation, temporary structures, vendors, etc.
35. Estimated Number in Attendance*
36. Estimated Number of Vehicles*
38. STREET/TRAIL CLOSURES: REQUIRES CITY COUNCIL PERMISSION
40. Are temporary street closures needed?*
    -- Select One --YesNo
41. Does the event cross at any intersections?*
    -- Select One --YesNo
43. Any street closures or crossing of intersections will require a Pleasant Hill Police Officer. The event will be responsible for the cost of this service and the cost of barricades. Event Director will need to coordinate this with the Pleasant Hill Police Department.
    Click here to download the street closure permit.
45. Will you be using the trails?
    -- Select One --YesNo
47. EVENT PARKING, IF APPROVED BY STAFF
49. Are you requesting vehicles be permitted to drive or park on city park grounds?*

    1. Yes
    2. No
51. If yes, please explain:
53. NOISE PERMITS MAY REQUIRE CITY COUNCIL APPROVAL BY RESOLUTION
55. Will you be using amplified sound/speakers, live music, and/or a public address system?

    1. Yes
    2. No
57. If you will be having live music or amplified sound at your event, you will need an approved permit.
    Click here to download the noise permit application.
59. SANITATION: TRASH, PORTABLE TOILET AND ELECTRICITY
61. Park trash cans are for daily park users. Event attendance over is over 75 additional trash cans will be required by the event organizers. Organizers must also remove their own trash collected.
63. The applicant must provide portable restrooms at city approved locations for each 75 people expected in attendance. The units must be maintained throughout the event and removed the next business day upon completion of the event.
65. Will extra portable toilets be needed?
    -- Select One --YesNo
66. Will additional electrical services be required?*
    -- Select One --YesNo
68. If yes, please describe. If a generator is required, please indicate the size and location on where it would be placed on the site plan.
70. TEMPORARY STRUCTURES
72. Will your event have infatable(s)?*
    -- Select One --YesNo

    Approved inflatables must be set up by an insured company and a person from that company must be on site the entire time. Failure to do so will result in closing of the structure.
74. Will your event have tents?
    -- Select One --YesNo
76. If yes, please describe size and how it will be secured to the ground.
    No drilling or coring on any concrete or asphalt to secure a tent.
78. FIREWORKS/PYROTECHNICS: REQUIRES CITY COUNCIL APPROVAL BY RESOLUTION
80. Will you event have fireworks or pyrotechnics?*
    -- Select One --YesNo
82. Fireworks permit
    Click here to download the fireworks permit.
84. VENDORS
86. Individual food vendors must obtain a Temporary Food License from the Iowa Department of Inspections and Appeals. The event organizer will be responsible for this information. Failure to do so may result in fines or closing of the vendor.
88. Will your event have alcohol on site? *
    -- Select One --YesNo

    If yes, please provide liquor permit information.
89. Will your event have food vendors?
    -- Select One --YesNo
91. Food Trucks
    Click here to download the mobile food unit application

    Permits for Mobile Food Units are required for food truck vendors per City Ordinance (Chapter 122.12). Current application and license must be on display in the Mobile Food Unit. Annual licenses expire April 15th of each year. Completed application, applicable fees, photographs of Mobile Food Unit, and copy of Iowa Department of Inspection and Appeals Inspection Certificate are to be submitted via email or hard copy to: Pleasant Hill City Clerk’s Office 5160 Maple Dr, Suite A Pleasant Hill, Iowa 50327 msievert@pleasanthilliowa.org Fax: (515) 262-9570
93. VOLUNTEER INFORMATION
95. What is the number that will be volunteering at your event? *
96. Is there a volunteer organizer?*
    -- Select One --YesNo
98. If yes, please list name and contact information.
    **Any volunteers/event staff along a race route or road will be required to wear a reflective yellow vest on the outermost part of their clothing. Failure to have proper numbers of volunteers may result in the cancellation of the event or added costs to the event for city staff services.
100. Fees associated with the event*

     1. I fully understand the fees below and as an event organizer will be responsible for any fees associated with this event.

     • Shelter/Facility $40, if applicable
       
     • Liquor license required if applicable: Payable to the State of Iowa (Iowa Alcoholic Beverages Division)
       
     • Street Closure Permit, if applicable
       
     • Noise Permit $10, if applicable
       
     • Fireworks Permit $60, if applicable
       
     • Special Events Refundable Deposit $250
       
     • Police Services $55/hour/Officer – Billed to the event organizer after the event.
       
     • Fire & Rescue Services $55/hour/officer– Billed to the event organizer after the event.
       
     • Public Works/Parks Staff $55/hour/staff– Billed to the event organizer after the event.
       
     • City staff will try to provide event organizers an estimated cost for any services requiring city staff prior to the event; however this is only an estimate.
102. Hold Harmless Agreement
     Applicant hereby agrees to indemnify, defend, protect, and hold harmless, the City, its agents, employees, representatives, and elected officials, from and against any and all claims, losses, demands, liability, lawsuits, damages, or expenses (including, without limitation, reasonable attorney's fees), relating to, resulting from, or arising out of, directly or indirectly, the promotion and/or conduct in any way related to the activities in connection with that event, including but not limited to the activities of applicants, employees, volunteers, contractors, vendors, attendees or participants in the event which is the subject of the application.
104. Event Contact Name*
105. Date*
107. Electronic signature*

     1. By checking this box, I agree that all of the information in this application is accurate to the best of my knowledge.
109. Event site map/route
     Provide a detailed map of the event site including the locations of: street closures, event parking, additional dumpsters, portable toilets, water, or electricity, overnight stay areas, temporary structures (including interior layouts), fireworks demonstration area, and vendor booths. Attach additional maps if needed.
     
     Event site map is required—failure to submit with application will result in the event application being rejected.
     
     Please use the following legend when labeling the map:

     • Label street names, etc.
     • Routes for races, parades, etc.---->
     • Fencing (_ _ _ _)
     • Restrooms/Portable toilets (R)
     • Temporary Structures (TS)
     • First aid facilities (1stA)
     • Alcohol serving/consuming area (A)
     • Street Barricades (B)
     • Trash Cans (TC)
     • Admission/registration fee collection (F)
     • Parking (P)
     • Vendors (V)
     • Volunteer Locations (X)
     • Fireworks/Pyrotechnics (FP)
     • Generator (G)
111. GENERAL LIABILITY INSURANCE
     General liability limit $500,000-$1,000,000
     A. Events with little or no impact on the public.
     B. Events in City parks or on public property without alcohol.
     C. Large picnics in parks exceeding shelter occupancy and using other park areas.
     
     All other events – minimum liability limit $2,000,000 (Additional insured and governmental immunities endorsement is required.)
     A. Firework/Pyrotechnic displays
     B. Fundraising walks/run
     C. Sports contests
     D. Parades
     E. Events requiring street closures
     F. Events that expect large crowds on public property
     G. Large events taking place for more than one day
     H. Large events that include alcohol on public property
113. *ENDORSEMENTS WHEN REQUIRED
     1. Additional Insured Endorsement:
     Except for Workers’ Compensation and Professional Liability, the policies shall include the City Additional Insured Endorsement of: The City of Pleasant Hill, Iowa, including all its elected and appointed officials, all its employees and volunteers, all its boards, commissions and /or authorities and their board members, employees, and volunteers, are included as additional insured with respect to liability arising out of the Insured’s work and/or Services performed for the City of Pleasant Hill, Iowa. This coverage shall be primary to the additional insured, and not contributing with any other insurance or similar protection available to the additional insured, whether available coverage be primary, contributing, or excess.
     
     2. Governmental Immunities Endorsement:
     A. Non-waiver of Government Immunity The insurance carrier expressly agrees and states that the purchase of this policy and the including of the City of Pleasant Hill, Iowa, as an Additional Insured does not waive any of the defenses of governmental immunity available to the City of Pleasant Hill, Iowa, under Code of Iowa Section 670.4 as it now exists and as it may be amended from time to time.
     B. Claims Coverage The insurance carrier further agrees that this policy of insurance shall cover only those claims not subject to the defense of governmental immunity under the Code of Iowa Section 670.4 as it now exists and as may be amended from time to time.
     C. Assertion of Government Immunity The City of Pleasant Hill, Iowa, shall be responsible for asserting any defense of governmental immunity, and may do so at any time and shall do so upon the timely written request of the insurance carrier. Nothing contained in this endorsement shall prevent the carrier from asserting the defense of governmental immunity asserted by the City of Pleasant Hill, Iowa.
     D. Non-Denial of Coverage The insurance carrier shall not deny coverage under this policy and the insurance carrier shall not deny any of the rights and benefits accruing to the City of Pleasant Hill, Iowa , under this policy for reasons of governmental immunity unless and until a court of competent jurisdiction has ruled in favor of the defense(s) of governmental immunity asserted by the City of Pleasant Hill, Iowa.
     E. No Other Change in Policy The insurance carrier and the City of Pleasant Hill, Iowa, agree that the above preservation of governmental immunities shall not otherwise change or alter the coverage available under the policy.
     
     Certificate of Insurance Requirements:
     A Certificate of Insurance is required evidencing all required insurance coverage as provided above with any required endorsements attached so as to evidence their inclusion in the coverage. The Certificate of Insurance is due 30+ days before the Special Event.
     
     The following format is required:
     1.List the name of the Event and Date in the Description of Operations section.
     2. The following address must appear in the Certificate Holder section: City of Pleasant Hill, Iowa Special Event Application 5160 Maple Dr. Suite A; Pleasant Hill, Iowa 50327
     3. The Producer’s contact person’s name, phone number and e-mail address is required.
     4. Endorsements, as required, shall be included with the Certificate of Insurance to evidence that the policy has been endorsed.
     
     Additional Special Event Information

     • Pleasant Hill Parks & Recreation Department: 515-262-9368
     • Pleasant Hill Police Department: 515-265-1444
     • Iowa Alcoholic Beverages Division: 515-281-7400 or www.iowaabd.com
     • Iowa One-Call: 8-1-1 or www.iowaonecall.com
     • Polk County Public Health Department: 515-286-3798
     • Iowa Department of Inspections and Appeals - Food Safety dia.iowa.gov.
Leave This Blank:


115. 1. Receive an email copy of this form.
116. Email address

     This field is not part of the form submission.

117. Submit Submit and Print

* indicates a required field