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Home My WebLink About20122407.tiffRESOLUTION RE: APPROVAL OF SPECIAL EVENTS PERMIT ISSUED TO AMERICAN CANCER SOCIETY, AND AUTHORIZE CHAIR TO SIGN WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the American Cancer Society presented to the Board of County Commissioners of Weld County, Colorado, an application for a Special Events Permit for the sale of malt, vinous and spirituous liquors for consumption by the drink on the premises only, and WHEREAS, said applicant has paid the sum of ONE HUNDRED DOLLARS ($100.00) to Weld County, Colorado, pursuant to the laws providing therefore in payment for a County Retail Permit for the sale of malt, vinous and spirituous liquors for consumption by the drink on the premises only, for an event scheduled for one day only on September 22, 2012, from 5:00 p.m., to September 23, 2012, at 12:00 a.m., outside the corporate limits of any town or city in the County of Weld at the location described as follows: 37440 County Road 43, Eaton, Colorado 80615; being further described as part of the SW1/4 of Section 27, Township 7 North, Range 65 West of the 6th P.M., Weld County, Colorado WHEREAS, said applicant has also paid the sum of TWENTY-FIVE DOLLARS ($25.00) to the Colorado Department of Revenue, and has exhibited a State Special Events Permit for the sale of malt, vinous, and spirituous liquors for consumption by the drink on the premises only. NOW, THEREFORE, BE IT RESOLVED that the Board of County Commissioners of Weld County, Colorado, having examined said application and the other qualifications of the applicant, does hereby grant Special Events Permit #2012-18 to said applicant to sell malt, vinous and spirituous liquors for consumption by the drink on the premises only, only at retail at said location; and the Board does hereby authorize and direct the issuance of said permit by the Chair of the Board of County Commissioners, attested to by the Clerk to the Board of Weld County, Colorado, which permit shall be effective from 5:00 p.m. on September 22, 2012, until 12:00 a.m. on September 23, 2012, providing that said place where the permitee is authorized to sell malt, vinous and spirituous liquors for consumption by the drink on the premises only, shall be conducted in strict conformity to all of the laws of the State of Colorado, and the Weld County Code and the rules and regulations relating thereto, heretofore passed by the Board of County Commissioners of Weld County, Colorado, and any violations thereof shall be cause for revocation of the permit. Cc = 47(.6,9- Ci4 2012-2407 Q -,9q -/a LC0022 SPECIAL EVENTS PERMIT - AMERICAN CANCER SOCIETY PAGE 2 BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said application. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 10th day of September, A.D., 2012. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ATTEST: Sean P. Conj ay, Chair C l` Weld County Clerk to the Board Kirkmeyer vid E. Lo ougl.s Radem- her Date of signature: q I S -1 a 2012-2407 LC0022 DR 8428 (08/01/2012) COLORADO DEPARTMENT OF REVENUE 1881 PIERCE STREET, SUITE 108 LAKEWOOD, CO 80214 STATE OF COLORADO DEPARTMENT OF REVENUE VALID ONLY FOR THE ORGANIZATION AT THIS LOCATION AMERICAN CANCER SOCIETY 37440 WCR 43 EATON CO 80615 Permit Number: 4800268 Event Manager: NANCY CLARK SPECIAL EVENTS PERMIT MALT, VINOUS AND SPIRITOUS LIQUOR VALID ONLY FOR THE FOLLOWING PERIODS EVENT 1: 09/22/2012 5:00PM 12:00AM EVENT 2: EVENT 3: EVENT 4: EVENT 5: This permit is issued subject to the laws of the State of Colorado and especially under the provisions of Title 12, Articles 46 or 47, CRS 1973, as amended. This permit is nontransferable and shall be conspicuously posted in the place above described. This permit is only valid during the event date(s) shown above. In testimony whereof, I have hereunto set my hand. 9/21/2012 RLE Division Director Executive Director taarrrarr-MCMCMCM.C:CM? 4 O O N 4 Tmul N N U H License Fee $100.00 te ti L 0 z 0 t0.8 -NC 0 i4 -afJ 0 O 0 UM H J a U W a m z 0 b 0 0 0 O O pa Atira FOR A SPECIAL EVENTS PERMIT TO SELL AT RETAIL MALT, VINOUS, AND SPIRITUOUS LIQUOR (CIa CD tee et PC V 6 O 4.4 O C E U U 'S V V c w H O O • 7) U .••••4 CA E'1 .54 V � -c V ct O v; r4-4 ' o O-4 UO V cn V t V ` O •z V V U ct 0 0 (I)VV o O � 1.4 CI iii te CLI t.4.-1 V V 4-1 Crn CS O � n V 0 C t4 •C O O a `"CA 0 E o U V V -E v o . L 41-4 . O � �C rn r Is .- O U en C V4 -1."O �Cli rd . be .. W V ;� rn eel . C rn o et x r o ct V C a V U 0 O N d' et M M V 3—i cu 3-4 V O .� b w O CCU) - cn Q U cct U) 3-4 ct O O ;"1 U) • U) 1-4 Ct 0 N L-1 O O O N O N 4-4 eN 0 0 ct -O L4-4 LL4 1 rfp w O U 0 • U) •, O (a) 1-4 V Cl Cld O V V r0 O 4 O V Cl V O V 0 V • U) 4 U) .� b • 1-4 Colorado Revised Statues, as amended. hereunto subscribed sioners has a U 0 O 0 -15 x z O H authorized this 10th day of September, 2012. cn N 0 0) 0 0 w 0 Pal v r O 'l. • r 1 k2E) '\ ~ �v �Y J`- r' ..: �....--- C- Z tThi z z O z 1) J U z O U 4 Q w t; O H DR 8439 (06/28/06) COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION 375 SHERMAN STREET DENVER CO 80261 rsm' ons_oann IN AND ORDER TO QUALIFY FOR A SPECIAL EVENTS PERMIT, YOU MUST ONE OF THE FOLLOWING (See back for details.) SOCIAL ❑ ATHLETIC . FRATERNAL Ir CHARTERED BRANCH, LODGE OR CHAPTER Il PATRIOTIC III OF A NATIONAL ORGANIZATION OR SOCIETY POLITICAL ❑ RELIGIOUS INSTITUTION BE NONPROFIT ❑ PHILANTHROPIC INSTITUTION . POLITICAL CANDIDATE • MUNICIPALITY OWNING ARTS FACILITIES LIAB 2110 2170 1/ TYPE OF SPECIAL EVENT APPLICANT IS APPLYING FOR: MALT, VINOUS AND SPIRITUOUS LIQUOR $25.00 PER DAY FERMENTED MALT BEVERAGE (3.2 Beer) $10.00 PER DAY DO NOT WRITE IN THIS SPACE LIQUOR PERMIT NUMBER 1. NAME OF APPLICANT ORGANIZATION OR POLITICAL CANDIDATE American Cancer Society State Sales Tax Number (Required) 98-01790 Tax Exempt 2. MAILING ADDRESS OF ORGANIZATION OR POLITICAL CANDIDATE (include street, city/town and ZIP) 8221 W 20th Street Suite A Greeley, CO 80634 3. ADDRESS OF PLACE TO HAVE SPECIAL EVENT (include street, city/town and ZIP) 37440 WCR 43 Eaton, CO 80615 NAME DATE OF BIRTH HOME ADDRESS (Street, City, State, ZIP) PHONE NUMBER 4. PRES./SECY OF ORG. or POLITICAL CANDIDATE 5. EVENT MANAGER Nancy Clark 1820 Montview Blvd Greeley CO 80631 970.350.5019 6. HAS ISSUED 1/ APPLICANT ORGANIZATION OR POLITICAL CANDIDATE BEEN A SPECIAL EVENT PERMIT THIS CALENDAR YEAR? NO YES HOW MANY DAYS? 7. IS PREMISES NOW LICENSED UNDER STATE LIQUOR OR BEER CODE? ✓ NO YES TO WHOM? Ir771I 8. DOES THE APPLICANT HAVE POSSESSION OR WRITTEN PERMISSION FOR THE USE OF THE PREMISES TO BE LICENSED? y� Yes iii No LIST BELOW THE EXACT DATE(S) FOR WHICH APPLICATION IS BEING MADE FOR PERMIT Date 09/22/2012 Hours From 5p .m. To 12 a .m. Date Hours From .m. To m. Date Hours From .m. To .m. Date Hours From m. To .m. Date Hours From m. To .m. OATH OF APPLICANT I declare under penalty o perjury in the second degree that I have read the foregoing application and all attachments thereto, and that all information therein is true, correct, and complete to the best of my knowledge. SIGNATURE n Q� a- d - C L�.1_.LL TITLE Distinguished Events Director DATE 8/22/11 REPORT AND APPROVAL OF LOCAL LICENSING AUTHORITY (CITY OR COUNTY) The foregoing application has been examined and the premises, business conducted and character of the applicant is satisfactory, and we do report that such permit, if granted, will comply with the provisions of Tit e 12, Article 48, C.R.S., as amended. THEREFORE, THIS APPLICATION IS APPROVED. LOCAL LICENSING AUTHORITY (CITY OR COUNTY)• CITY Weld County, Colorado 0 COUNTY TELEPHONE NUMBER OF CITY/COUNTY CLERK (970) 356-4000 Ext 4225 SIGNATURE TITLE Chair, Board of County Commissioners DATE DO NOT WRITE IN THIS SPACE - FOR DEPARTMENT OF REVENUE USE ONLY LIABILITY INFORMATION License Account Number Liability Date State TOTAL $ • -750 (999) APPLICATION FOR A SPECIAL EVENTS PERMIT Department Use Only (Instructions on Reverse Size) SPECIAL EVENT PERMIT QUESTIONNAIRE AND AFFIDAVIT 1. What type of an event is planned (e.g., annual, quarterly, benefit, etc.)? annual benefit for the American Cancer Society (Cattle Barons Ball) 2. Explain in detail the nature of your organization, its function, and who or what benefits from its operations (attach separate sheet if necessary). Organization dedicated to preventing cancer, saving lives and diminishing suffering from cancer through research, education, prevention and advocacy. 3. Who or what organization will be the recipient of funds derived from this event? American Cancer Society 4. How many attendees are expected at this event? 840 guests, 260 vols & vendors 5. Describe the premises at which this event will take place. Spicer Arena - private property Indoor roping arena 6. What type of security will be provided at this event? Coordinated through John Cooke, Weld County Sheriffs office. Security for guests and property. 7. How many security personnel will be on hand? 17 - 20 people 8. How will security personnel be identified? some in uniform, some plains clothes 9. If this event is being held outdoors, how will the exterior boundaries of the premises be marked (e.g., roped, fenced, etc.)? Event is indoors. Guests, volunteers and vendors will be the only ones allowed on the property. Security bracelets will be worn by guests, volunteers & vendors. 10. What type of entertainment will be provided, if any, for this event? LeAnn Rimes - headliner 11. What method will be used in checking identification for proper age of attendees (e.g., at the door, at the bar, etc.) and how will underage patrons be identified so as not to be served alcoholic beverages (e.g., stamp or mark on the hand, etc.) Professional bartenders with training under the direction of UNC Catering. No drinking permitted for volunteers. Bartenders will id as necessary. 0 N N O N M:ICTBICTB FORMSIFOS P EC IAL EV ENT.DOCS pec ial Event 12. How will the conduct and level of intoxication of attendees be monitored and by whom? Bartenders, security, volunteers and event manager. 13. Have volunteers or members of your organization been trained in the sale/service of alcoholic beverages: If yes, what training have they received and by whom? UNC Catering is providing paid bartenders that they will supervise. 14. What types of alternate beverages and food/snacks will be available? Coffee, iced tea, infused water bar for guests. Full Course meal, appetizers & late night snack. 15. Has a State Sales Tax Number been initiated by you or a member of your organization? If so, write that number in the space provided. 98-01790 Sales Tax Exempt Number 16. Explain how this event will be marketed describing what kinds of advertising material will be distributed and the targeted recipients of such material. Invitations to event; general press releases to public. I hereby certify, under penalty of perjury, that the information provided to the Board of County Commissioners of Weld County contained in this affidavit is true and accurate to the best of my knowledge. ' -L!la.z P/;a )/a Applicant's Signature/ Date STATE OF COLORADO ss COUNTY OF WELD Subscribed and sworn to before me this c9a ad day of /4U yt,O1 20L Witness my hand and official seal. TONYA JOHNSON NOTARY PUBLIC STATE OF COLORADO NOTARY ID 20104042756 MY COMMISSION EXPIRES OCT. 7, 2014 My commission expires: /0 - —7- a -O/°/ M:\CTB\CTBFO RMS\FOS PEC IALEV ENT. DOGS pecia (Event APPLICATION INFORMATION AND CHECKLIST THE FOLLOWING SUPPORTING DOCUMENTS MUST BE ATTACHED TO THIS APPLICATION FOR A PERMIT TO BE ISSUED: Appropriate fee. Diagram of the area to be licensed (not larger that 8 1/2" X 11" reflecting bars, walls, partitions, ingress, egress and dimensions. Note: If the event is to be held outside, please submit evidence of intended control, i.e., fencing, ropes, barriers, etc. Copy of deed, lease, or written permission of owner for use of the premises. Certificate of good corporate standing (NONPROFIT) issued by Secretary of State within last two years; or If not incorporated, a NONPROFIT charter; or If a political Candidate, attach copies of reports and statements that were filed with the Secretary of State. }L APPLICATION MUST FIRST BE SUBMITTED TO THE LOCAL LICENSING AUTHORITY (CITY OR COUNTY) AT LEAST THIRTY (30) DAYS PRIOR TO THE EVENT. THE PREMISES TO BE LICENSED MUST BE POSTED AT LEAST TEN (10) DAYS BEFORE A HEARING CAN BE HELD. (12-48-106 C.R.S.) AN APPROVED APPLICATION MUST BE RECEIVED BY THE LIQUOR ENFORCEMENT DIVISION AT LEAST TEN(10) DAYS PRIORTO THE EVENT. CHECK PAYABLE TO THE COLORADO DEPARTMENT OF REVENUE (12-48-102 C.R.S.) A Special Event Permit issued under this article may be issued to an organization, whether or not presently licensed under Articles 46 and 47 of this title, which has been incorporated under the laws of this state for the purpose of a social, fraternal, patriotic, political or athletic nature, and not for pecuniary gain or which is a regularly chartered branch, lodge or chapter of a national organization or society organized for such purposes and being non profit in nature, or which is a regularly established religious or philanthropic institution, and to any political candidate who has filed the necessary reports and statements with the Secretary of State pursuant to Article 45 of Title 1, C.R.S. A Special Event permit may be issued to any municipality owning arts facilities at which productions or performances of an artistic or cultural nature are presented for use at such facilities. If an event is cancelled, the application fees and the day(s) are forfeited. 2012 SPICER ARENA CATTLE. BARONS BALL z W O W W 0 U T i i 6 a y cc a 8 9,4 .— I I I flay 9NLLV3 I I aa31Nn,ojl I I I 5 4.11 z Z a m i w ♦ ••• •e• •, • • .••. ■e• •• a. 5 8 w tow —m r a O S r co • •• • • • .. • .••• . .e •, • • • •• ♦ ■■ •••e• • •• ■•e■ ♦••• .e. •, • • • ••e•• •••• •e. • , • • ••• • •• ••••• ♦••• • . • ••• • •• ., •. O• • • .. 40 • •0• •••• •• •• • ••• • • •• •• • , • • • ♦ •• •• 4 • •* 0 •• •• ■e■ •, • •••• ■0■ •• •• ♦• • •• •••• •e • 2 O z .••• ••••e■ ♦•• •0• •, • • •••• • • . • • • •, •• •• e, • ♦••• •e■ •, • • a'1,7 •••• •e■ • •. • •0.• •, • • 1;34 la U 14 Z M a -- m .••• •e• S. ••• ♦ ••••e■ ♦••• •0• •, •♦ ••• • . .• *Op ••S • •••• ••. ♦ ■• •••••• .••, • .• • • •. ce Om Fz m z .•••• • • • •e.• ♦ • •• • •e■ •, • ♦ ♦ •. ••••• •• •• • •e■ •, • • .0• . •• • ♦ • •• • ■ •. W• •. ♦ ••• ••e• • .. • •• ♦ •e • • • ♦• •• • ■•Q■ • •• ••• e. • • •0• •, • • •• •• •S S •• , • • •• •♦ • • • • , • • •• ••©• ♦ • •• •e■ • , • • ♦• •• •• •e •• •• • # •, •. • •• ♦ •• • 443 • •. •,•• • • •• •e• •• •• • •• •• • •• z aAna wg 'a 0 _C 39Nno'1 1334013 d(JI S "o oIII 1111110 1 S ♦• •• ■O• •, • •• •• ■Q• •, • • • •. • . ♦ • •• ••••• ♦ • • • •■ • e• •♦ ♦••• S • •• •• •A• •, • • ♦••• •e• •• •• a co � �♦ • • 4.5 ca z m to a U T Y W= ma I / Z r toa . a F a x 2 N RESTROOM 33' RESTROOM 33' RESTROOM £5' ta S OFFICE OF THE SECRETARY OF STATE OF THE STATE OF COLORADO CERTIFICATE I, Scott Gessler, as the Secretary of State of the State of Colorado, hereby certify that, according to the records of this office, AMERICAN CANCER SOCIETY, INC. is an entity formed or registered under the law of New York has complied with all applicable requirements of this office, and is in good standing with this office. This entity has been assigned entity identification number 20031215132. This certificate reflects facts established or disclosed by documents delivered to this office on paper through 09/19/2012 that have been posted, and by documents delivered to this office electronically through 09/20/2012 @ 11:10:35. I have affixed hereto the Great Seal of the State of Colorado and duly generated, executed, authenticated, issued, delivered and communicated this official certificate at Denver, Colorado on 09/20/2012 @ 11:10:35 pursuant to and in accordance with applicable law. This certificate is assigned Confirmation Number 8344329. Secretary of State of the State of Colorado ***************:k********t*******************End of Certificate***:*********r** •******•► *a1************** Notice: A certificate issued electronically from the Colorado Secretary of State's Web site is filly and immediately valid and effective. However, as an option, the issuance and validity of a certificate obtained electronically may be established by visiting the Certificate Confirmation Page of the Secretary of State's Web site, http://ww ,os state.co. us, brs'CerdticateSearchCriteria.do entering the certificate's confirmation number displayed on the certificate, and following the instructions displayed. Confirming the issuance of a certificate is merely optional and is not necessary to the valid and effective issuance of a certificate. For more information. visit our Web site. lutp"" www.sos.state.co.us/ click Business Center and select "Frequently Asked Questions." CERT GS_F 08/10/2008 OFFICE OF THE SECRETARY OF STATE OF THE STATE OF COLORADO CERTIFICATE I, Mike Coffman, as the Secretary of State of the State of Colorado, hereby certify that, according to the records of this office, AMERICAN CANCER SOCIETY, GREAT WEST DIVISION, INC. is a Nonprofit Corporation formed or registered on 07/28/1995 under the law of Colorado, has complied with all applicable requirements of this office, and is in good standing with this office. This entity has been assigned entity identification number 19951095742 • This certificate reflects facts established or disclosed by documents delivered to this office on paper through 08/07/2008 that have been posted, and by documents delivered to this office electronically through 08/13/2008 (a, 16:15:08 • I have affixed hereto the Great Seal of the State of Colorado and duly generated, executed, authenticated, issued, delivered and communicated this official certificate at Denver, Colorado on 08/13/2008 @ 16:15:08 pursuant to and in accordance with applicable law. This certificate is assigned Confirmation Number 7157539 • Secretary of State of the State of Colorado **********«***************************** End of Celli fleatee*************************************** Notice: A certificate issued electronically from the Colorado Secretary of State's Web site isfdly and immediately valid and effective, flowerer, as an option, the issuance and validity oa certificate obtained electronically may be established by visiting the Certificate Conformation Page of the .Secretary of Slate's Web site. lutp:GN•ww sos. stale.co,oibi /CertiticateSearchCriteria do entering the certificate's confirmation number displayed on the certificate. and following the instructions displayed. C'onlirmine the issuance of a certificate is merely optional and is not necessaryto the valid andeffective issuance aft, certificate. For more information. visit our Web site. htip:iiwww.sos.state.co.us/ click Business Center and select "Frequently Asked Questions." CERT_GS I) Revised 01/0212007 37440 WCR 43 Eaton, CO 80615 November 3, 2010 American Cancer Society c/o Nancy (:lark 8221 W. 20th Street, Suite A Greeley, CO 80634 8.07.2012 Dear Nancy With regard to your application for permits and licenses for the Cattle Barron's Ball to be held on Saturday, September 22, 2012, this letter sets forth the position of Spicer Arena. The land chosen for the event to occur, known as Spicer Arena, is owned by Rebecca Meyring. The mailing address fur Spicer Arena is 37440 WCR 43, F.atnn, CO 80615. The festivities will be held in the southwest corner of WCR 43 and 76 also known as SW 1/4 of Section 27, Township 7 North, Range 65 West of the 6a' PM, Weld County Colorado. This letter verifies Rebecca Meyring has granted permission for the event to occur at the location indicated above. Spicer Arena or Rebecca Meyring will have no role or liability in the activities of the event including the license or permits. If you have any questions feel free to call. Sincrely, � 1 ' • LA �t-' i/L. i 1 / ,Z X fir'_-� _ '�-.� �' Rebecca Meyring 139199 ACORO� CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YVYY) 8/30/2012 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 pollcy(les) must 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 Commercial Lines - (404) 923-3700 Wells Fargo Insurance Services USA, Inc. 3475 Piedmont Road NE, Suite 800 Atlanta GA 30305-2886 INSURED American Cancer Society, Inc. 250 Williams Street Atlanta, GA 30303 =ACT Andy Adams PH404 923 3526 FAX 877-362-9069 jAIC NONE . E..ql ... __- jA/C, M h ADDRESS andrew.adams@wellsfargo.com INSURER(S) AFFORDING COVERAGE NAICp INSURER A Federal Insurance Company 20281 INSURER e: Pacific Indemnity Company 2D346 INSURER C. INSURER 0: INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: 4794754 REVISION NUMBER: See below THIS INDICATED. CERTIFICATE EXCLUSIONS INSR LTR IS TO CERTIFY THAT THE NOTWITHSTANDING MAY BE ISSUED AND CONDITIONS _.. TYPE OF INSURANCE POLICIES ANY OR OF SUCH REQUIREMENT, MAY OF INSURANCE PERTAIN, POLICIES. ADDL INSR SUOR—.-._ WVO LISTED BELOW HAVE BEEN TERM OR CONDITION OF ANY THE INSURANCE AFFORDED BY LIMITS SHOWN MAY HAVE BEEN REDUCED -...... --_ POLICY NUMBER ISSUED TO CONTRACT THE POLICIES BY POLICY EFF (MM/DDNYYY) THE INSURED OR OTHER DESCRIBED PAID CLAIMS. POLICY EXP (MM/DOWYYY) NAMED ABOVE FOR THE POLICY PERIOD DOCUMENT WITH RESPECT TO WHICH THIS HEREIN IS SUBJECT TO ALL THE TERMS, LIMITS A GENERAL LIABILITY 35943463 09/01/2012 09/01/2013 EACH OCCURRENCE -DAMAGE - $ - ------ 1000,000 -- X COMMERCIAL GENERAL LIABILITY TO RENTED- PREMISES (Ea_occurrence) _. $ -- 300,000 ---___ l' CLAIMS -MADE T X-; OCCUR MEDEXP (Any one person) $ 2,500 PERSONAL & ADV INJURY $ 1000000 GENERAL AGGREGATE $ 25.000,000 GE 'L AGGREGATE LIMIT APPL PER: PRODUCTS-COMP/OPAGG - --. _...-.__. - $ 2,000000 X POLICY JECT PRO- LOC $ A AUTOMOBILE LIABILITY 73563471 09/01/2012 09/01/2013 COMBINED SINGLE LIMIT 1000000 X ANY Auto 73563476 -Puerto Rico BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS 73563477 -Hawaii BODILY INJURY (Per accident) $ X HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ OED I RETENTION$WORKERS COMPENSATION X WC STATU- OTH- B AND EMPLOYERS' LIABILITY 71741355 09/01/2012 09/01/2013 ----- -TORYh1LT L_S__-._._ER___.__.--_._.. ANY PROPRIETOR/PARTNER/EXECUTIVE vIn E L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N NIA ------- --- --- --- - (Mandatory In NH) E L. DISEASE EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS bel i E.L. DISEASE- POLICY LIMIT $ 1.000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Certificate holder is included as an additional insured in accordance with the terms and conditions of the general Lability policy. Re: Cattle Barons Ball 2012 on September 22, 2012 6pm to 12am at Spicer Arena, 3744O WCR 43, Eaton, CO 80615. CERTIFICATE HOLDER CANCELLATION Weld County Government Clerk to the Board Office, Tonya Disney 1150 "O" St Greeley, CO 80631 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(44• am 9 'l 5 ACORD 25 (2010/05) The ACORD name and logo are registered ma k of ACORD © 1988-2010 ACORD CORPORATION. All rights reserved. I �IIDI� I I II II I0III VIII WII III I III II 1101 ��IIl uhII IDA 1101 �� It� itEAVCO Audiovisual RENTAL & STAGING DIVISION 6240 W. 54th Avenue Arvada CO 80002 Phone: 303-539-3500 Fax: 303-539-3501 JH 2012 Cattle Baron's Ball American Cancer Societ Reservation No.: DEN34258 Prepared By: Joe T Hartman CEAVCO Delivery CEAVCO Pickup Terms: Client PO4: After Hours Emergency Pager - 303-539-3505 09/21/2012 09:00 AM 09/23/2012 02:00 AM Net 30 Client: 1678 Contact: Phone: Fax: AMERICAN CANCER SOCIETY/GREELEY 8221 W. 20TH STREET; SUITE A GREELEY,CO 80634 NANCY CLARK 970-350-5019 Cell Phone: 970-356-9238 nancy.clark@cancer.org Ship To: Spicer Arena 37440 WCR 43 Eaton,CO 80615 Contact: Site Ph: Room: Cell Phone: Equipment Qty Item Description Large Audio System Main PA to Speaker, Powered Vertec JBL VT4888DP-AN / Line Array 1 Rigging Kit, VT4888 3' (Line Array) 2 Speaker Kit, 4 JBL Dual 18" Subs 1 Constant Curvature Line Array - JBL VRX932, Speaker Support 2 Chain Motor Kit. 3 Phase, .5TON, Model F With 3 Phase to Edison Breakout Front of House Mix 1 Yamaha M7CL48 Mixer w/Rack Kit I Instant Replay Kit, Digital Audio Recorder -Player w/Editing Monitor Mix 1 Yamaha M7CL48 Mixer w/Rack Kit 3 Monitor System, In -Ear* 2 Speaker Kit, JBI, SRX 712 4 Monitor Wedge w/NL4 Cable 1 Backline Gear Per Rider* Stage Inputs I Performance Microphone Kit #1 I Kit, Tripod Mic Stands 1 Trunk, XLR Cable for Performance Mic / Line Array 1 Wireless Mic Kit, Shure UHF R L3 System (2)HH (2) Lay 2 Mic, Dual Polar Pattern Condenser, Cardioid/Omnidirectional KSM141 1 Mic, PZM SHURE SM-91 A 2 Mic, Cardioid Conderser w/Shockmount SHURE KSM-32 2 Mic, Handheld Vocal Large -Diaphragm Condenser Cardioid E965 Communication 1 ClearCom Music Kit. 2 CCPhone & 2 Flashers 2 ClearCom 1 -Channel Belt Pack RS-601(Blue) 2 Intercom Headset , Telex PH -88 1 Monitor, LCD 23" 1080P HD w/Pedestal, Kit 1 Radio Kit x 4 w/Chargers Support Gear I Audio Accessory, Workbox tools and Supplies Kit 1 Show Power Distro Medium Kit I Trunk, Cable AC #2 Feeder 5 Wire Discountable Sub Total Days Unit Price Item Subtotal 1.00 175.00 1750.00 1.00 0.00 0.00 1.00 600.00 1200.00 1.00 1000.00 1000.00 1.00 75.00 150.00 1.00 400.00 400.00 1.00 100.00 100.00 1.00 400.00 400.00 1.00 0.00 0.00 1.00 400.00 800.00 1.00 2000.00 2000.00 1.00 300.00 300.00 1.00 48.00 48.00 1.00 0.00 0.00 1.00 250.00 250.00 1.00 35.00 70.00 1.00 25.00 25.00 1.00 35.00 70.00 1.00 35.00 70.00 1.00 70.00 70.00 1.00 7.50 15.00 1.00 0.00 0.00 1.00 125.00 125.00 1.00 100.00 100.00 1.00 0.00 0.00 1.00 250.00 250.00 1.00 200.00 200.00 7743.00 CEAVCO Order:DEN34258 Page 1 of 5 Printed on 07/05/2012 At 10:31 AM Your signature below indicates: You specifically agree to be bound by all the terms and conditions listed on the last page of this contract. Accepted and agreed (Printed Name) Date CEAVCO Order:DEN34258 Page 5 of 5 Printed on 0 710 512 01 2 At 10:31 AM 2 Hotel/Lodging Expenses* 2 Per Diem for Technicians/Crew* Pre function ( Single person band ) 1 PA System. 2 SRM450 & Mixer 1 Direct Box. AV -1A 2 Mic, Instrument Unidirectional SIIURE SM57-LC 1 Stand, Mic Floor Stackable, Ultimate MC -87 I Stand, Mic Tripod Large I Boom, Mic Tripod Stand Need lift and generator in place thursday Sam. JLG E300AJP Electric Boom Lift * indicates non -discountable items Labor Personnel 4.00 89.00 4.00 56.00 1.00 150.00 1.00 25.00 1.00 25.00 1.00 5.00 1.00 5.00 1.00 5.00 712.00 448.00 150.00 25.00 50.00 5.00 5.00 5.00 Set up Labor Thursday On -Site Coordinator/Manager, Day Rate* Audio Operator (Al), Day Rate* Lighting Director (LD), Day Rate* Lighting Operator, Day Rate* Audio -Video Technician, Day Rate* Rigger* Focus and Rehearsal Friday 7pm On -Site Coordinator/Manager, Day Rate* Audio Operator (Al), Day Rate* Lighting Director (LD), Day Rate* Lighting Operator* Show Labor Saturday On -Site Coordinator/Manager, Day Rate* Audio Operator (Al), Day Rate* Lighting Director (LD), Day Rate* Lighting Operator, Day Rate* Strike Labor On -Site Coordinator/Manager, Day Rate* Audio -Video Technician, Day Rate* Rigger* Summa Contract Notes rY Qty Rate RT OT DT Subtotal I 650.00 LOO 1 550.00 1.00 I 550.00 1.00 1 475.00 1.00 6 475.00 1.00 2 500.00 1.00 I 650.00 1.00 I 550.00 LOO I 550.00 1.00 I 475.00 1.00 I 650.00 1.00 1 550.00 1.00 1 550.00 1.00 1 475.00 1.00 I 650.00 1.00 10 475.00 LOO 2 500.00 LOO 650.00 550.00 550.00 475.00 2850.00 1000.00 650.00 550.00 550.00 475.00 650.00 550.00 550.00 475.00 650.00 4750M0 1000.00 Shipping Comments Equipment Delivery - Shipping Sales & Expenses Labor Damage Waiver Service Charge Discount RLCOLO Sales Tax TOTAL AMOUNT 26630.50 650.00 1160.00 16925.00 0.00 0.00 7279.65 0.00 $38,085.85 CEAVCO Order:DEN34258 Page 4 of 5 Printed on 0 710 512 01 2 At 10:31 AM I Dimmer Rack, 48 Channel 20A. Sensor 48 I MLD 208D - L6-20 Moving light distro* 1 Trunk, Cable AC 4/0 Feeder 5 Wire I Trunk, AC Cables / AC Strips I Cable Kit, DMX Large I Trunk. Cable AC 6 CH SOCO (CO Springs) Spare Cable 1 Trunk. Ballroom Rigging Hardware / Denver I Trunk, Steel Rigging Hardware / Denver I Lighting Accessory, Workbox tools and Supplies Kit 2 Hazer. Neutron SX Sub Total 30% Discount Net Amount Video Sponsor Equipment Screens hung on sides I Projector Kit, Eiki LC-XT4 w/Lens & Stacker 2 Screen Kit, 91x 12' Stumps Monoblox I DVI Splitter Kit / 1 X 2 Gefen 3 Cable, RGBHV 50 Meter (162') I DA, RGBHV 1 x 6 ADA 6 300 3 Cable, DVI Directional Fiber Optic HDTV 50 Meter I Switcher, Seamless Graphics, ImagePro HD Kit 1 DVD Player, Pro w/PAL Conversion DVD-V800 Kit 2 Laptop B Computer Kit, 6735b I Cue light w/2 wireless actuators Sub Total 30% Discount Net Amount Sponsor Gobo's 6 Light, Source 4 Ellipsoidal Zoom 15-30 Degree 5 Metal GOBO 1 Decor, 8' White Spandex Circle w/4 Eyelets 2 Decor, Spandex, 4 Point Splat #1 IFR, 12' x 12', White (PINK BAG) 2 Decor, Spandex. 4 Point Splat #1 IFR, 15' x 15'. White (PINK BAG) I Decor, Spandex, 4 Point Splat #1 IFR, 10' x 10', White (PINK BAG) 1 Decor, Spandex, White Circle, 8', w/4 Eyelets (WHITE BAG) Sub Total 30% Discount Net Amount Production Tools I Pipe and Drape/Tech Kit, Black, Full Coverage Limit 24', 5' H, Den 2 Pipe and Drape Kit, Black, Full Coverage Limit 40', 16' H 1 Boom Pipe and 501b Base Kit I Duvetyn Fabric, 54" x 50 yards (150 feet) I Rubber Carpet 100' 1 Ladder, 7' 1 Ladder, 10' 1 Ladder, Little Giant MT -22. 7' - 21' Sub Total 30% Discount Net Amount 2 Delivery / Pick -Up - Fort Collins - 12'-24' "Truck* Client to provide security in the building CEAVCO Order:DEN34258 1.00 250.00 1.00 0.00 1.00 100.00 1.00 0.00 1.00 100.00 1.00 150.00 1.00 75.00 1.00 75.00 1.00 0.00 1.00 100.00 1.00 1000.00 1.00 100.00 1.00 50.00 1.00 35.00 1.00 50.00 1.00 80.00 1.00 450.00 1.00 100.00 1.00 125.00 1.00 60.00 1.00 25.00 1.00 95.00 1.00 125.00 1.00 125.00 1.00 125.00 1.00 125.00 1.00 125.00 1.00 125.00 1.00 240.00 1.00 25.00 1.00 50.00 1.00 0.00 1.00 0.00 1.00 0.00 1.00 0.00 250.00 0.00 100.00 0.00 100.00 150.00 75.00 75.00 0.00 200.00 11837.50 (3551 25) 8286.25 1000.00 200.00 50.00 105.00 50.00 240.00 450.00 100.00 250.00 60.00 2505.00 (75/.50) 1753.50 150.00 475.00 125.00 250.00 250.00 125.00 125.00 1500.00 (450.00) 1050.00 125.00 480.00 25.00 50.00 0.00 0.00 0.00 0.00 680.00 (204.00) 476.00 1.00 325.00 650.00 Page 3 of 5 Printed on 07/05/2012 At 10:31 AM 30% Discount Net Amount Band Stage Lighting Upstage Lighting Position I Truss Kit, Vertical Uprights for backlight I Trunk, Lighting AC 6 CH SOLO Trunk (Denver) I Dimmer Kit, Sensor 12 Show Kit 1 Trunk, Cable AC 2/0 Feeder 5 Wire 24 Lighting Kit, Parnel w/Clamp 4 Light, Moving Head MAC -700 Profile* I Gel Cuts, Basic Color Correction, Gel Kit I Gel Cuts, Decor Color, Gel Kit Downstage Lighting I Truss Kit, 20.5" x 20.5" x 40' w/ Bolts & Tools I 2 Chain Motors w/Controller Kit, .5TON / CS800 1 Trunk, Lighting AC 6 CH SOCO Trunk (Denver) 1 Lighting Cable Kit, Stage Pin I Lighting Kit, Parnel w/Clamp Midroom lighting effects 8 Light, Moving Head* 3 Lighting kit, Color Blast w/12 CB12 TR 1 Lighting Cable Kit, Stage Pin Lighting for all uprights 2 Lighting kit, Color Blast w/12 CB12 TR (2322.90) 7420.10 1.00 290.00 290.00 1.00 150.00 150.00 1.00 225.00 225.00 1.00 100.00 100.00 1.00 25.00 600.00 1.00 0.00 0.00 1.00 15.00 15.00 1.00 15.00 15.00 1.00 140.00 140.00 1.00 225.00 225.00 1.00 150.00 150.00 1.00 0.00 0.00 1.00 25.00 25.00 .00 0.00 0.00 .00 720.00 2160.00 .00 0.00 0.00 .00 720.00 1440.00 Auction and Cocktail Area, reception I Truss Kit, 60' Following the rack of the roof using Omni Truss 1.00 170.00 170.00 2 Truss Kit. 60' Following the rack of the roof using Omni Truss 1.00 150.00 300.00 1 8 Chain Motors, 3 Phase, w/ Controller Kit..5TUN / CS800 1.00 675.00 675.00 2 Chain Motor Kit, 3 Phase, .5TON, Model F With 3 Phase to Edison Breakout 1.00 75.00 150.00 1 "trunk, Ballroom Rigging Hardware / Denver 1.00 75.00 75.00 14 Lighting Kit, Source Four Complete w/19° Lens 1.00 25.00 350.00 12 Lighting Kit, Source Four Complete w/26° Lens 1.00 25.00 300.00 12 Lighting Kit, Source Four Complete w/36° Lens 1.00 25.00 300.00 4 Lighting Kit, Source Four Complete w/50° Lens 1.00 25.00 100.00 4 Lighting Kit, Source Four Complete w/10° Lens 1.00 25.00 100.00 1 Dimmer Kit, Sensor 24 Show Kit 1.00 500.00 500.00 I Lighting Cable Kit, Stage Pin 1.00 0.00 0.00 19 Sand Bag, 50 Lbs Black 1.00 7.50 142.50 Auction Table Uprights I Truss Kit, 4 Uprights at ends of tables I Lighting kit, Color Blast w/6 CB12 TR 4 Light, Moving Head MAC -700 Profile* Bar Lighting Setup 1 Truss Kit, Bar Upright 3 Truss Kit. Bar Upright I Lighting kit, Color Blast w/6 CB12 TR 8 Lighting Kit, PAR38 W/Clamp Control and Support I Lighting Controller Kit, Road Hog w/Wing Expansion CEAVCO Order:DEN34258 Page 2 of 5 1.00 320.00 320.00 1.00 300.00 300.00 1.00 0.00 0.00 1.00 140.00 140.00 1.00 120.00 360.00 1.00 300.00 300.00 1.00 15.00 120.00 1.00 650.00 650.00 Printed on 07105/2012 At 10:31 AM ovo. COLORADO MEMORANDUM To: Tonya Johnson, Deputy Clerk to the Board August 24, 2012 From: Bethany Salzman, Zoning Compliance Officer II, Dept. of Planning Services Subject: LC0022 Review of the following request for a Temporary Assembly Permit and a Special Events Permit by the Department of Planning Services shows the following: Type of Event: Cattle Barons Ball (Fundraiser for the American Cancer Society) Applicant: American Cancer Society Attn: Nancy Clark 8221 West 20th Street, Suite A Greeley, Colorado 80634 Location of Event: 37440 CR 43 Eaton, CO 80615 Dates and Time of Event: September 22, 2012 5:00 p.m. to Midnight General Information: Zone District: A (Agricultural) This site is currently permitted through USR-1633. A hearing before the Board for both the Temporary Assembly Permit and the Special Events Permit is scheduled for September 10, 2012, at 9:00 a.m. according to Docket #2012-72. No overnight camping shall accompany this Temporary Assembly permit or Special Events permit. There are no outstanding zoning violations on this site and staff has no issues with issuance of this "Temporary Assembly Permit" or the "Special Events Permit". SERVICE, TEAMWORK, INTEGRITY, QUALITY Memorandum TO: Tonya Johnson FROM: Dan Joseph SUBJECT: Temporary Assembly Application DATE: September 5, 2012 CC: Cindy Salazar; Debra Adamson In response to your request, Environmental Health Services has reviewed the Temporary Assembly Permit for the American Cancer Society, located at 37440, in Eaton, Colorado. After reviewing the application, the Department does not have any additional requirements or concerns. Should you have any questions regarding this matter, please contact me at extension 2206 or via e-mail at dioseph(&co.weld.co.us. Thank you. cc: Cindy Salazar, Environmental Health Services Deb Adamson, Environmental Health Services Tonya Johnson From: Sent: To: Subject: Jonathan Gesick Thursday, September 06, 2012 8:10 AM Tonya Johnson RE: Temporary Assembly/Special Events Permit - American Cancer Society c/o Nancy Clark No Concerns. Sorry I was late. Jonathan D Gesick Plans Examiner/Building Inpsector Building Department 1555 N 17th Ave Greeley, CO 80631 tel.: (970)353-6100 Ext. 3532 Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Tonya Johnson Sent: Wednesday, August 22, 2012 4:46 PM To: Bethany Salzman; Dan Joseph; Janet Carter; Jeremy Frey; Jonathan Gesick; Lisa Carpenter; Roy Rudisill Cc: Brad Yatabe; David Clarke; Deb Adamson; Margie Martinez; Sara Evans; Tonya Johnson Subject: Temporary Assembly/Special Events Permit - American Cancer Society c/o Nancy Clark The following applicant has submitted a request for a Temporary Assembly Permit, LC0022. Please provide any comments you may have before September 6, 2012. A .pdf copy of the application materials is attached. Applicant: American Cancer Society Attn: Nancy Clark 8221 West 20th Street, Suite A Greeley, Colorado 80634 970-350-5019 nancy.clark@cancer.orq rq Thank you, Tonya (Disney) Johnson Clerk to the Board 1150 0 Street IPO Box 758 Greeley, Colorado 80632 1 Phone: 970-336-7215 x 5226 trjohnson®co.weld.co.us Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. 2 To: Weld County Board of Commissioners From: Deputy Lisa Carpenter Date: September 5, 2012 RE: American Cancer Society Dear Commissioners, I have researched and found no reported calls for service to the American Cancer Society Event, located at 37440 WCR 43, Eaton, CO 80615 for the Calendar year of 2011 to present day. The Weld County Sheriffs Office Posse, Reserves and the Mobile Command Center will be at the event. I find no grounds for disapproval for the Special permit license. Respectfully Subpjitted, Deputy Lisa Carpenter Community Resource Officer Weld County Sheriffs Office 1950 "O" Street Greeley, CO 80631 TEMPORARY ASSEMBLY REVIEW FORM Date: August 22, 2012 TO: Lisa Carpenter/Jeremy Frey FROM: CTB — Tonya Johnson SUBJECT: Temporary Assembly/Special Events Permit Inquiry Please review all records on the following property for any associated reports during the last year and return your report to the Weld County Clerk to the Board's Office. Your report will be used by the Board of County Commissioners in considering issuance of a Temporary Assembly Permit. A copy of the file will be attached in .pdf format for your review. PLEASE RESPOND NO LATER THAN: September 6, 2012 APPLICANT: AMERICAN CANCER SOCIETY EVENT LOCATION: 37440 COUNTY ROAD 43 EATON, CO 80615 (PROPERTY OF REBECCA MEYRING) EVENT DATE: SEPTEMBER 22, 2012, FROM 5:00 P.M TO MIDNIGHT ******************************************************************************************************** No concerns ys Initials The Sheriffs Office had a concern and the deputy has mutually worked with the property owner to correct the concern. (Complete Attached Worksheet) Unresolved concerns exist requiring a Probable Cause Hearing scheduled by the Board of County Commissioners. (Complete Attached Worksheet) ******************************************************************************************************** Please notify at Extension Board of Commissioner's Temporary Assembly hearing. of the date and time of the Temporary Assembly Worksheet The following concerns are noted: The property owner and the Sheriffs Office have collectively agreed to implement the following to correct concerns noted above: (A time line and corrective action should be listed for each concern) 9- s Property Owner, Please Print Property Owner Signature Date Deputy' Signature Use another sheet of paper or attach separate proposal to this packet if needed. Attach copies of all reports associated with this property for the last year. Both the Deputy and the Owner of the establishment will be required to attend the Temporary Assembly Hearing to testify to the above agreement. MEMORANDUM TO: Tonya Johnson, Clerk to the Board DATE: 09/06/12 FROM: Janet Carter E.I., Public Works SUBJECT: Temporary Assembly American Cancer Society The Weld County Public Works Department has reviewed this proposal. Our requirements are as follows: REQUIREMENTS: 1. No parking will be allowed on Weld County Roadways. 2. Approximately 600 vehicles will require parking on the property 3. This area is in a Special Flood Hazard Area (SFHA) as determined by the Federal Emergency Management Agency (FEMA). 4. Please submit a Traffic Control Plan (TCP) prepared by a certified Traffic Control Supervisor (TCS) 5. Please submit an Incident Action Plan for the Office of Emergency Management. Page - 1 - of 1 September 6, 2012 C.\Documents and Settings\tdisney\Local Settings\Temporary Internet Files \Content.Outlook\YNN5FDU2\Temp Assembly American Cancer Society 2012.DOC I • Air Ai • • • • •••••••••• a I1'.. • w• . 0. -/I P.. r _ 7 -7"/"11,, igle .—cr - et.„ t 1 i 1.4° ilir iii4 //11 , , I ., alsimifts .. .tr dal;al/ eV. 4 i p //f/ air: / /11:/, / ft \j'Ae.46444.7e 4. Air / ifie it.: 44:, ew , es,. cur 474.... , / ily/ 4 11 s .- ar if 0 Oa ciph.,:// r • , .. :I 2 if NIIIIr. . . , 4 v • J Do • , t • • - • 111 let t r ., ' . . . -. - s r "t% siii + ♦! .a • • " i - I '• `• .• , •4• r ► • I-•II • • r II ti 1D II f a �. � � • L • 7,,c,:r;Dir‘jalli• • 1' • • a • •\IIF . � , ts i v t • � a r f • , 7 itirr k : - .7 i • 4...• .8: : ' . '� • w 1 • y 1lit • , 1 139199 "v o® CERTIFICATE OF LIABILITY INSURANCE DATE AT 9;62012 "' 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 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 Commercial Lines -(404)923-3700 Wells Fargo Insurance Services USA, Inc' 3475 Piedmont Road NE, Suite 800 Atlanta, GA 30305-2886 CONTACT Andy Adams PHONE 404-923-3526 I FAX 877-362-9069 (NC No EMI' IA/C, No): E-MAILSS: andrew.adams@wellsfargo.com INSURER(S) AFFORDING COVERAGE NAIC It INSURER A: Federal Insurance Company 20281 INSURED American Cancer Society, Inc. 250 Williams Street Atlanta, GA 30303 INSURER B: Pacific Indemnity Company 20346 INSURER C : INSURER D: INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: 4822277 REVISION NUMBER: See below 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 OF INSURANCE ADDLTYPE JNSR SUER WVD POLICY NUMBER EFF (MM/DDY/YYYY) (MM/DD/YEYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY ,INSR 35943463 09/01/2012 09/01/2013 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 300,000 MED EXP (Any one person) $ 2.500 CLAIMS -MADE X OCCUR PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 25,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 GEN'L AGGREGATE X POLICY LIMIT APPLIES PRO- JFCT PER: LOC $ A AUTOMOBILE X X LIABILITY ANY AUTO ALL OWNED SCHEDULED NON -OWNED AUTOS 73563471 73563476 -Puerto Rico 73563477 -Hawaii 09/01/2012:09/01/2013 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident $ PROPERTY DAMAGE (Per accident) UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY OFFICER/MEMBER EXCLUDED? PROPRIETOR/PARTNER/EXECUTIVE (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below YIN N NIA 71741355 09/01/2012 09/01/2013 X I WC STATU- I TORY LIMITS OTH- FR E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE- EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000 $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Certificate holder is included as an additional insured in accordance with the terms and conditions of the general liability policy. Re: Cattle Barons Ball 2012 on September 22, 2012 6 pm to 12 am at Spicer Arena, 37440 WCR 43, Eaton, CO 80615. ELLATION Weld County Government Tonya Disney, Clerk to the Board Office 1150 "0" Street Greeley, CO 80631 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 9( The ACORD name and logo are registered marks of ACORD -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) 19. PrW zo w O goo o J J 2 1-- u W oa (Qa< W No r zQ w K W a a0 r w U) z w U J ♦ Detach Here The Weld County and State of Colorado Special Events Liquor Licenses and a Temporary Assembly Permit for the American Cancer Society were picked up by Nancy Clark, representative, on June 21, 2012. arm Representative: American Cancer Society Witnessed by \,r, oom, q -3J -/c2 Deputy C rk t td hBoard Hello