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Home My WebLink About20152923.tiffRESOLUTION RE: APPROVAL OF SPECIAL EVENTS PERMIT ISSUED TO AMERICAN CANCER SOCIETY, INC., 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, Inc., 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 19, 2015, from 5:30 p.m., to September 20, 2015, 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: 3695 65th Avenue, Greeley, CO 80634; being further described as part of Section 21, Township 5 North, Range 66 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 2015-17 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 5:30 p.m. on September 19, 2015, until 12:00 a.m. on September 20, 2015, 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 =So 2015-2923 LC0022 SPECIAL EVENTS PERMIT - AMERICAN CANCER SOCIETY, INC. 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 2nd day of September, A.D., 2015. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ATTEST: dd1;vk EXCUSED Barbara Kirkmeyer, Chair Weld County Clef to the Board Q e Freeman, Pro-Tem hty Attorney Date of signature: /11S/L* Steve Moreno 2015-2923 LC0022 rT1 a w w z w U .a x F-4 Wera..C.M.M.CWWWWWW.C4� �JJ� �JJ� �JJ' JJ, JJ` J../1 J..11 �J 1r11 �l M W 1 0 V C4 cn r• ci. 0 M to O 1-4 cid vs) 0 N 0 0 et U w 0 4J ame: C U loS M 0000 O U a) a, y`TCJ'-GJ'-Cy'-Gym-Gy'-Gym-Cyr-Gym-GJ�-GJ'--C_y'-CJ'-CJ'-CJ'-CJ'J' G' GJ'-GJ�GJ�CJ �� NON -TRANSFERABLE. w U U z O U d 094 F O a O F 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 INC ST. MICHAEL'S RESERVOIR ESTATE 3695 65TH AVENUE GREELEY CO 80634 Permit Number: 4801579 Event Manager: NANCY CLARK SPECIAL EVENTS PERMIT MALT, VINOUS AND SPIRITOUS LIQUOR VALID ONLY FOR THE FOLLOWING PERIODS EVENT 1: 09/19/2015 5:30 PM 12 AM 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. 9/10/2015 JM Division Director Executive Director DR 8439 (06/28/06) COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION 1375 SHERMAN STREET DENVER CO 80261 (303) 205-2300 IN ORDER TO QUALIFY FOR A SPECIAL EVENTS PERMIT, YOU MUST BE NONPROFIT AND ONE OF THE FOLLOWING (See back for details.) SOCIAL ATHLETIC I♦ PHILANTHROPIC INSTITUTION El FRATERNAL ! CHARTERED BRANCH, LODGE OR CHAPTER POLITICAL CANDIDATE II PATRIOTIC M OF A NATIONAL ORGANIZATION OR SOCIETY M MUNICIPALITY OWNING ARTS POLITICAL RELIGIOUS INSTITUTION FACILITIES LIAB TYPE OF SPECIAL EVENT APPLICANT IS APPLYING FOR: 2110 ,./MALT, VINOUS AND SPIRITUOUS LIQUOR $25.00 PER DAY 2170 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, INC. State Sales Tax Number (Required) 9,5,j -- oil 90 2. MAILING ADDRESS OF ORGANIZATION OR POLITICAL CANDIDATE (include street, city/town and ZIP) 8221 W 20th St Suite A Greeley CO 80634 3. ADDRESS OF PLACE TO HAVE SPECIAL EVENT (include street, city/town and ZIP) 3695 65th Avenue Greeley CO 80634 NAME DATE OF BIRTH HOME ADDRESS (Street, City, State, ZIP) PHONE NUMBER 4. PRES./SEC'Y OF ORG. or POLITICAL CANDIDATE 5. EVENT MANAGER Nancy Clark 1820 Montview Blvd Greeley CO 80631 970-350-5019 6. HAS ISSUED APPLICANT A SPECIAL ORGANIZATION OR POLITICAL CANDIDATE BEEN EVENT PERMIT THIS CALENDAR YEAR? YES HOW MANY DAYS? 7. IS PREMISES NOW LICENSED UNDER STATE LIQUOR OR BEER CODE? ii NO YES TO WHOM? 8. DOES THE APPLICANT HAVE POSSESSION OR WRITTEN PERMISSION FOR THE USE OF THE PREMISES TO BE LICENSED? IJ Yes II No LIST BELOW THE EXACT DATE(S) FOR WHICH APPLICATION IS BEING MADE FOR PERMIT Date 9/19/2015 Hours From 5:3O p m. To 12.00 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 of perjury in the second degree that / 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. SIGNA UR /a /1 .),-2O.4„/(,C/ /l.rt/!) TITLE /y]p�^ Senior Sj_!f_iWa_ll1E+t, Distinguished Events DATE 08/07/2015 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 Title 12, Article 48, C.R.S., as amended. THEREFORE, THIS APPLICATION IS APPROVED. LOCAL LICENSING AUTHORITY (CITY OR COUNTY) lil CITY Weld County, Colorado QJ COUNTY TELEPHONE NUMBER OF CITY/COUNTY CLERK (970) 356-4000 Ext 4225 SIGNATURE , --- Pro—Tem, TITLE Board of County Commissioners DATE SEP 0 2 2015 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) 2015-2923 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. 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 ATLEASTTEN(10)DA YSPRIORTO 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. 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, Inc. 4. How many attendees are expected at this event? 1000 guests, 275 volunteers/vendors 5. Describe the premises at which this event will take place. On private property, setting up tents on a grass area 6. What type of security will be provided at this event? Coordinated through Donnie Patch, Commander with Weld County Sheriffs Office. Security for property & guests 7. How many security personnel will be on hand? 13 - 17 people 8. How will security personnel be identified? Some in uniform, some in plain clothes 9. If this event is being held outdoors, how will the exterior boundaries of the premises be marked (e.g., roped, fenced, etc.)? Property is fenced. Has two gates, which will be monitored. Guests, volunteers and vendors will be the only ones allowed on property. Security bracelets to be worn by guests and volunteers. 10. What type of entertainment will be provided, if any, for this event? Craig Morgan 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 direction of Kenny's Catering. Bartenders will ask for ID as needed. Alcohol limited to guests only. M:ICTBICTBFORMSIFOSPECIALEVENT.DOCSpecialEvent Witness my hand and nffirial conL.— RAFAELA ALICIA MARTINEZ NOTARY PUBLIC STATE OF COLORADO NOTARY ID 20144002878 MY COMMISSION EXPIRES JANUARY 22,2018 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? Kenny's Steakhouse is providing professional bartenders. 14. What types of alternate beverages and food/snacks will be available? Coffee, Iced Tea, Water, Full meal with appetizers and late night snacks. 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. 98-17123000 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 know edge. I Applicants S ignat re STATE OF COLORADO ss COUNTY OF WELD Date poi/1/45- Subscribed and sworn to before me this 'Olt day of 611,(01— , 20/6. mmission expiresJQ/L1,tnkt o7 i aol s wado. L:c.; aoY Public M:\CTB\CTBFORMS\FOSPECIALEVENT.DOCSpecialEvent OFFICE OF THE SECRETARY OF STATE OF THE STATE OF COLORADO CERTIFICATE I, Wayne W. Williams, 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 08/07/2015 that have been posted, and by documents delivered to this office electronically through 08/10/2015 @ 11:28:39. 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 08/10/2015 @ 11:28:39 pursuant to and in accordance with applicable law. This certificate is assigned Confirmation Number 9271611. Secretary of State of the State of Colorado *********************************************End of Certificate******************************************** Notice: A certificate issued electronically from the Colorado Secretary of State's Web site is fully 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:/hvww.sos.state,co.us/biz/CertfcateSearchCriteria.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, http://www.sos.state.co.us/click Business Center and select "Frequently Asked Questions." CERT US_F Revised 08/20/2008 ,ot O NW CHUCK WAGON RUMORS- RESTR00MS ADA Yz33'-o• -. e -9'X33 O• . AY r j 1 w oeE �e• -- TAX NNVS i-mwA \ / 0 L- o F' x a 53'Id O� /\ 2, s - A a \w / \ I__�_7- l -J W / Lv- IJ / \ / / \ \/ / \ 0 O q r N0U fV av1 00000 0000 0000 os 0000 0.0 000 . t7 !x1 00000 00000 0000 00000 0000 00000 0000 OOOOc:doc= 3 ! 0000 00000 0000 s'o q C LI_ sin] (MVO 3HVls r� O OV 0 0to q \ / / \ 3 F s0 0 COO o 2 :ncuJr. °c°15y- o Q W DR 0010 (01/18/12) STATE OF COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT LICENSE TO OPERATE A RETAIL FOOD ESTABLISHMENT ACCOUNT NUMBER LIABILITY INFORMATION use for all references 2 0000 county city THIS LICENSE MUST BE POSTED AT THE FOLLOWING LOCATION: KENNY'S STEAK HOUSE 3502 10TH ST GREELEY, CO 80634 Owner: STAMPEDE STEAK RANCH LLC LICENSING AGENCY: WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT T,lG171; cl1 tl `i.61' "I REVOR JIRICEK, M.A. E.S., DIRECTOR ENVIRONMENTAL HEALTH SERVICES indust. type liability date 3275 1/1/1996 ISSUE DATE month day year 12/17/2014 LICENSE VALID TO DECEMBER 31 2015 This certifies that licensee shown hereon is authorized and licensed to engage in business in accordance with the provisions of the law and regulations of the Colorado Department of Public Health and Environment. Any alterations made on this license will automatically make it null and void. POST IN A CONSPICUOUS PLACE Department of Revenue. If you do not, check your Junk email folder. Once you have your Authorization Code return to Revenue Online via DR 0140 (02/16/11) DEPARTMENT OF REVENUE DENVER CO 80261-0013 Must collect taxes for: SALES TAX LICENSE STATE COLORADO USE ACCOUNT LIABILITY INFORMATION NUMBER for all references ISSUE DATE county Qty I,dusiry type Iiadsty date. month yea LICENSE VALID TO DECEMBER 31 00366277-0000 03-0057-017 L THIS LICENSE MUST BE POSTED AT THE FOLLOWING LOCATION IN A CONSPICUOUS PLACE: STAMPEDE STEAK RANCH 3502 W 10TH ST GREELEY CO 80631-5008 I"'IIIII'IIII'II"III'III'I"I'III►IIJIIJIIIIIIII,III,II IIlIII.I KENNY'S STEAK HOUSE 3502 W 10TH ST GREELEY CO 80634-1824 050195 Nov 26 13 2015 THIS LICENSE IS NOT TRANSFERABLE Executive Director Department of Revenue ST. MICHAEL'S RESERVOIR ESTATE, LLC 23691 HIGHWAYS 263 GREELEY, CO 80631 July 30, 2015 American Cancer Society c/o Nancy Clark 8221 W. 20th Street, Suite A Greeley, CO 80634 Dear Nancy, With regard to your application for permits and license for the Cattle Barons Ball to be held Saturday, September 19, 2015 this letter sets forth the position of St Michaels Reservoir Estates, LLC as owner of the property where the American Cancer Society's Cattle Barons Ball event will be held. The location chosen for the event to occur is known as St. Michael's Reservoir Estate, LLC and is at 3695 65th Avenue Greeley, Colorado 80634. The mailing address for St. Michael's Reservoir Estate, LLC is 23691 Highway 263, Greeley, Colorado 80631. This letter verifies that St Michael's Reservoir Estate, LLC as owner of the property has granted permission for the event to occur at the date and location indicated above. St Michaels Reservoir Estate, LLC will have no role or liability in the activities of the event including license or permits. Respectfully, it4b(4k, Art Guttersen Manager, St Michaels Reservoir Estate, LLC 970-978-8888 Page 3 of 6 FL EXX TENTS •EVENTS productions PARTY RENTALS 1833 E. Harmony #19 Fort Collins, CO 80528 Office: 970.223.1195 Fax: 970.226.0528 www.FLEXXproductians.com (Customer #: 22 American Cancer Society 970-350-5019 Phone 8221 W 20th Street Sutie A Job Descr: CBB 2015, Event 9/19 Greeley, CO 80634 Salesman: PHILIP Gottula Phone: 970-223-1195 E -Mail: PHIL@FLEXXProductions.com Delivery and Pickup Delivery: Mon 9/14/2015 8:00AM - 5:00PM Pickup Date: Mon 9/21/2015 8:00AM - 5:00PM Location: Gutterson Ranch Used at Address: 3695 65th Avenue ; Greeley, CO 80634 Delivery Notes: PG Main tent to start install 09/09 or 09/10 Del- start install 9/14/14. Pu 9/20/14- must be out end of day Thursday 9/24/14. Final counts to be received by 09/07/15 ACS to take napkins on Wednesday 9/15/15. Contact: Nancy Clark Phone: 970-396-9545 Status: Reservation Contract #: 12685 Event Beg: Sat 9/19/2015 5:00PM Event End: Sat 9/19/2015 11:00PM Operator: PHILIP Gottula Terms: On Account FLEXX will start installing on 9/10/14, main tent. Cocktail tent on 9/12. Event date: Sept 19th 2015 Start un-install 9/20, off property by 9/24. Tables and chairs set by Thursday and linens on site. 8' Tables- Silent Auction 25, Live Auction, 2, Raffle 2, Sales 4, Bank & Vault 9, Kitchen 30, Photo 1, Registration 6, Beverage 2. Linens for 8' tables- Silent Auction 25, Live Auction, 2, Raffle 2, Sales 4, Bank & Vault 9, Photo, 1, Registration 6, Beverage 2. Qty Items Rented Each Price Guest Seating 1 Tent- 66x98 Clearspan $10,672.20 $10,672.20 S.A. Tent 10 Tent-Sidewall Solid-Clearspan 13hx16w $64.00 $640.00 6 Tent-Sidewall Window-Clearspan 13hx16w $80.00 $480.00 Going on N side of tent 1 Structure Tent 132'x246' $76,309.20 $76,309.20 Includes solid walls 2 Tent-Sidewall Window-Clearspan 13hx16w $80.00 $160.00 Going next to exit near restrooms 1 Gutter between tents 15m (48') $540.00 $540.00 1 Tent -30x40 Clearspan $960.00 $960.00 Registration Tent 10 Tent-Sidewall Solid-Clearspan 8x10 $20.00 $200.00 1 Custom gutter between SA & Reg $540.00 $540.00 101 Table -Round 6' $12.25 $1,237.25 870 TBLC- Napkin- PLUM $0.65 $565.50 86 TBLC- 120" Round- KHAKI $15.35 $1,320.10 150 TBLC- 120" Round- BURGUNDY $15.35 $2,302.50 VIP 150 TBLC- Napkin- EGGPLANT $0.65 $97.50 VIP 1010 Chair -White Wood Style Padded $3.50 $3,535.00 1020 China -Silver Rim - Dinner $0.55 $561.00 1020 Flatware -Steak Knife (Black Handle) $0.75 $765.00 1020 Flatware- Pearl - Dinner Fork $0.55 $561.00 1020 China -Silver Rim - Salad/Dessert 7" $0.55 $561.00 Salad 2040 Flatware -Pearl - Salad/Dessert Fork $0.55 $1,122.00 Salad & Dessert Printed On Fri 7/17/2015 3:34PM Software by Point -of -Rental Software www.point-of-rental.com Modification # 7 Contract-Params.rpt (8) Contract #: 12685 American Cancer Society Pac!2 4 of 6 Qty Items Rented Each Price 1020 China -Silver Rim - Bread & Butter 6" $0.55 $561.00 For Dessert 202 China -Silver Rim - Bread & Butter 6" $0.55 $111.10 BB plates, 2 per table 202 Flatware -Pearl - Butter Knife $0.55 $111.10 1020 Glass -Water 17oz $0.55 $561.00 750 Glass -Wine 13.5oz $0.55 $412.50 270 Glass -Wine 12oz $0.55 $148.50 Subbing in for reds 30 Glass -Crystal Water 16oz $1.65 $49.50 VIP 300 Glass -Irish Coffee $0.55 $165.00 40 Serving -Creamer White $6.35 $254.00 30 Serving -Thermal Coffee Pitcher White $4.00 $120.00 202 Serving -Salt & Pepper set $1.50 $303.00 2 sets per table 202 Serving -Bread Baskets Wicker $2.50 $505.00 2 per table 202 TBLC- Napkin- KHAKI $0.65 $131.30 85 Serving -Pitcher -Plastic $2.75 $233.75 1 Trough -Metal 2 Keg $20.00 $20.00 Guest waters Bars 10 Bar -6' Complete w/Linen & Skirt Black $75.00 $750.00 Bars 1-2 2 Trough -Plastic 1/2 Size $17.00 $34.00 For Stage bar 2 Trough -Metal 2 Keg $20.00 $40.00 For main bars 18 Table -Banquet 6' $7.50 $135.00 Bar backs 18 TBLC- 90"x132" Bqt- BLACK $18.35 $330.30 Auction Tables, area items 6 Easel Tri-Pod METAL $10.00 $60.00 6 SA 1 Raffle Drum Brass $22.00 $22.00 81 Table -Banquet 8' $8.50 $688.50 See notes 51 TBLC- 90"x156" Bqt- KHAKI $20.35 $1,037.85 See Notes 30 Chair -White Wood Style Padded $3.50 $105.00 Other activities, 2 raffle, 2 sales, Vault 2, Photo 2, Games 2, Reg 18, Production 2 Dance Floor, Main Stage 96 Dance Floor 4x4 Indoor/Outdoor $25.00 $2,400.00 24'x64' 30 Stage -Deck 4X8 $65.00 $1,950.00 Main stage 24'x40'x30" 35 Stage -legs 24"-36" $2.50 $87.50 145 Stage -legs 32"-56" $2.50 $362.50 1 Stage- 4 Step Unif $55.00 $55.00 88 Stage -Skirting per foot $1.25 $110.00 80' for main 1 Stage -8x8 $130.00 $130.00 24" high- Auctioneer stage 24 Stage -Skirting per foot $1.25 $30.00 Restroom/Smoking area 12 Lighting -Par 64 Light $25.00 $300.00 2- for restroom #2. Color gels 12 Extension Cord 50' $4.65 $55.80 6 Extension Cord 3 -way Plug $1.87 $11.22 Volunteer Area 1 Tent -Frame Tent 20x60 White KIT $735.00 $735.00 8 Tent-Sidewall White 8'x20' $40.00 $320.00 Ponied On Fri 7/17/2015 3:34PM Software by Point-of.Rental Software www.point-of-rental.com Modification # 7 Contract-Params.rpt (8) Contract #: 12685 American Cancer Society Page 5 of 6 Qty Items Rented Each Price 2 Tent -Frame Tent 10x10 $130.00 $260.00 4 Tent-Sidewall White 8'x10' $20.00 $80.00 1 Lighting -Tent Lighting Package $315.00 $315.00 12 20x60 and 2-10x10 Table -Banquet 8' $8.50 $102.00 3 TBLC- 90"x156" Bqt- BLACK $20.35 $61.05 70 2 buffet, 1 beverage Chair -Folding Black $1.25 $87.50 1 Kitchen Gear Tent -Pole Tent 40x80 White $1,440.00 $1,440.00 11 Food Prep Tent Tent-Sidewall White 8'x20' $40.00 $440.00 3200 Flooring -Plywood Floor Per SOFT $1.85 $5,920.00 2 40x80 tent Tent -Frame Tent 10x10 $130.00 $260.00 4 Tent-Sidewall White 8'x10' $20.00 $80.00 1 2 per tent Tent -Frame Tent 20x20 white $270.00 $270.00 2 Kitchen Tent Tent-Sidewall White 8'x20' $40.00 $80.00 1 Tent -Frame Tent 10X20 KIT $210.00 $210.00 2 Kitchen to main tent Tent-Sidewall White 10'x10' $35.00 $70.00 1 Outside kitchen light and tent $385.00 $385.00 6 Lighting -Halogen 2-500W on Tri-Pods $25.00 $150.00 4 Flooring -Entry Rug 3'x5' $7.50 $30.00 35 Floor/cord covers Catering -Bakers Rack Tall open $40.00 $1,400.00 6 Oven -Warming Tall Must have (240V/20 AMP) Outlet $150.00 $900.00 400 Serving -Sheet Pan $3.50 $1,400.00 40 China -Square - Dinner 11" $0.75 $30.00 100 App plates Table -Leg Extenders $1.65 $165.00 30 Trash Can Plastic 32 Gallon with Liner $7.00 $210.00 30 MAKE SURE TO SEND LINERS Pipe & Drape -8' Black Drape Panel $8.35 $250.50 5 Trash can wrap Catering -Heat Lamp $25.00 $125.00 4 Oven -Convection w/ 40lbs propane $190.00 $760.00 1 Pot Burner Single w/propane 20LBS $28.00 $28.00 2 Hand Sinks Portable $160.00 ' $320.00 30 Catering -Bus Tub $4.00 $120.00 2 Water Tank 65 Gallon $95.41 $190.82 204 Serving -Gravy Boat SS 8oz $4.15 $846.60 10 Chair -Folding Green $1.15 $11.50 2 For Kitchen Fire Extinguisher 5LBS $15.00 $30.00 3 Extension Cord 100' $6.65 $19.95 5 Kitchen/extras Extension Cord 50' $4.65 $23.25 5 For Kitchen Extension Cord 25' $3.65 $18.25 11 Kitchen/extras Extension Cord 50' $4.65 $51.15 1 Kitchen/extras AV -Podium Full Oak delux $75.00 $75.00 60 Pipe & Drape 8' (PerFT) $3.25 $195.00 11 Side of the stage Weight Rubber 30LBS $4.00 $44.00 1 Beam clamps for Ceavco $360.00 $360.00 1020 6 Clamps Set -Up Chairs $0.50 $510.00 1020 Take Down -Chair $0.50 $510.00 263 Take Down -Table $1.00 $263.00 Printed On Fri 7/17/2015 3:34PM Software by Point -of -Rental Software www.point-of-rental.com Modification # 7 Contract-Params.rpt (8) Contract #: 12685 American Cancer Society Page 6 of 6 Qty Items Rented Each " Price 263 Set -Up Tables $1.00 $263.00 1 Delivery/Pickup Greeley $375.00 $375.00 Thank you for your Business! Rental Contract IMPORTANT. PLEASE READ CAREFULLY BEFORE SIGNING: This is a legally binding Contract. Important Terms and Conditions appear on the Reverse Side and/or following page(s) hereof (and on any Instructions and/or Addenda referenced herein or included herewith). Any different or additional terms, oral or written, are hereby objected to, and shall not be enforceable unless separately and specifically approved in writing by FLEXX Productions, LLC ("Lessor"). The undersigned "Customer" or "Lessee" represents, warrants, covenants and agrees that he/she/it has carefully reviewed, understands, and agrees to the terms of this Contract (as well as all applicable Instructions and Addenda), has received complete and legible copies of each, and hereby PERSONALLY GUARANTEES the prompt payment and performance of all obligations of the "Customer" or "Lessee" arising under or in connection with each of the same. Signature: American Cancer Society Rental: Sales: Delivery Charge: \ $134,380.24 $1,546.00 $375.00 Subtotal: $136,301.24 Larimer County 3.5: $0.00 Total: $136,301.24 Paid: $0.00 Amount Due: $136,301.241 Printed On Fri 7/17/2015 3:34PM Software by Point -of -Rental Software www.point-of-rental.corn Modification # 7 Contract-Params. rpt (8) IrkicEAvco AudioVisual 6240 W. 54th Avenue Arvada CO 80002 Phone: 303-539-3500 Fax: 303-539-3501 ACS Cattle Baron's Ball 2015 Reservation No.: DEN38771 Prepared By: Version: CEAVCO Delivery CEAVCO Pickup Terms: Client PO#: After Hours Emergency Pager - 303-539-3505 Joe T Hartman 1 09/17/2015 08:00 AM 09/20/2015 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: Contact: Site Ph: Room: Art Guttersen's 3695 65th Avenue Greeley,CO 80634 Cell Phone: Equipment Qty Item Description Audio Main Stage and Room Audio. Band audio and Live Auction 1 Line Array System, JBL VerTec 4888DP-AN 1 Scaffolding, 2 Audio PA Tower, 6' 2 Speaker Kit, 4 JBL Dual 18" Subs 1 Yamaha M7CL48 Mixer w/Rack Kit, (1) White Case 1 Yamaha M7CL48 Mixer w/Rack Kit, w/Dugan Automixer, (2) Black Case 1 C1earCom Music Kit, 2 CCPhone & 2 Flashers 1 Audio, Snake, 250' W4 40 X 16 2 Way Iso Split, Kit 1 Speaker Kit, JBL SRX 712 4 Monitor Wedge w/NL4 Cable 3 Speaker Kit (2), VRX932 w/Power & Patch Cables 1 Rigging Kit, VRX932 3' (Compact Line Array) 1 Subwoofer Kit, VRX918 w/Power Cable & Adjustable Stand 1 Mic, Wired, Performance Microphone Kit #1 1 Trunk, XLR Cable for Performance Mic / Line Array 2 Podium Mic Kit, Countryman M4HP18RF 2 Kit, Tripod Mic Stands 1 In Ear Monitor, Wireless, Shure PSM900 Kit (470-506MHz) 1 Mic, Wireless, Shure UHF R L3 System (4)HH (4) Lay, Kit 1 Intercom, Wireless Kit w/4 1 Channel TR700 Stations BTR700 B4 1 Mic, Wireless, Antenna, Helical Antenna, 460-900Mhz/Kit 1 Radio Kit x 6 w/Charger Sub Total Silent Auction Tent, Separate System with mic and overflow feed from main room I PA System, 1402 VLZ3 With Cable 4 Speaker Kit, Single Powered Speaker w/Stand EON510 1 Mic, Wired, Handheld w/Switch SHURE, SM-58S 1 Stand, Mic Floor Stackable, Ultimate Sub Total Band Needs 1 Backline Gear* Sub Total Audio Discountable Total CEAVCO Order:DEN38771 Printed On:07/16/2015 Days Unit Price Item Subtotal 1.00 2000.00 2000.00 1.00 100.00 100.00 1.00 600.00 1200.00 1.00 400.00 400.00 1.00 400.00 400.00 1.00 80.00 80.00 1.00 100.00 100.00 1.00 400.00 400.00 1.00 180.00 540.00 1.00 0.00 0.00 1.00 180.00 180.00 1.00 300.00 300.00 1.00 0.00 0.00 1.00 35.00 70.00 1.00 48.00 96.00 1.00 600.00 600.00 1.00 500.00 500.00 1.00 300.00 300.00 1.00 100.00 100.00 1.00 150.00 150.00 7516.00 1.00 50.00 50.00 1.00 35.00 140.00 1.00 25.00 25.00 1.00 5.00 5.00 220.00 1.00 2500.00 2500.00 2500.00 7736.00 Page 1 of 5 35% Discount Audio Total Lighting Stage Lighting, Basic system for event support and stage 1 Truss Kit, Upstage 43' x 16' OD 1 Truss Kit, Down Stage 60' 20.5" 1 Truss Kit, House 60' 12" 1 Chain Motor (8), 3 Phase, w/ Controller Kit, .5TON / CS800 2 Lighting, Moving Head, MAC Viper Profile 2 Pack/kit 2 Light, LED Par 5 RGBWA 12ct Kit 8 Lighting Kit, ETC Source 4 Complete w/26° Lens 1 Lighting Controller Kit, Road Hog w/Wing Expansion 1 Dimmer Rack, 48 Channel VX Series, Leprecon 1 Power Distro, 200A Cam In/Out 9 L21-30;2 Soca Motion Labs 1 Lighting Accessory, Workbox tools and Supplies Kit 1 Lighting Control, Opto Splitter 1 in 6 out DMX 8863/5 1 Trunk, Lighting AC 6 CH SOCO Trunk (Denver) 1 Trunk, Cable AC 1 Cable, DMX, Lighting Support Kit 1 Trunk, Cable AC 2/0 Feeder 5 Wire Sub Total Band Lighting, added gear to make the performance awesome! 30 Lighting Kit, ETC Source 4 PARNel w/Clamp 2 Lighting, Moving head, MAC Aura 6 Pack /Kit 2 Audiance Blinder* 6 Lighting, Moving Head, MAC Viper Profile/or Mac 700 Sub Total Small Stage Lighting 4 Lighting Kit, ETC Source 4 Complete w/10° Lens 2 Lighting Kit, ETC Source 4 PARNel w/Clamp and Bamdoor Sub Total Tent Lighting, Moving lights for ceiling effects and color and table illumination 4 Lighting, Moving Head, MAC Viper Profile* 8 Lighting, Moving Head, MAC Aura* 1 Truss Kit, Lighting truss 10' x 4 Sub Total Followspots9999? 1.00 555.00 1.00 230.00 1.00 170.00 1.00 675.00 1.00 350.00 1.00 360.00 1.00 25.00 1.00 650.00 1.00 350.00 1.00 100.00 1.00 0.00 1.00 50.00 1.00 0.00 1.00 0.00 1.00 350.00 1.00 0.00 1.00 25.00 1.00 450.00 1.00 50.00 1.00 175.00 (2707.60) 7528.40 555.00 230.00 170.00 675.00 700.00 720.00 200.00 650.00 350.00 100.00 0.00 50.00 0.00 0.00 0.00 0.00 4400.00 750.00 900.00 100.00 735.00 2485.00 1.00 35.00 140.00 1.00 25.00 50.00 190.00 1.00 1.00 1.00 175.00 75.00 400.00 700.00 600.00 400.00 1700.00 Sub Total 0.00 Dance Floor Lighting, dynamic moving lights for just the dance floor. 1 Lighting, Moving Head, MAC Viper Profile 2 Pack/kit 6 Lighting, Moving Head, MAC Aura* Sub Total Auction Area Tent, White light for tables and Colored back wall I Ground Support Grid 2 Crank Up Stand ALPS Kit W/ Truss Adapter, 496 lbs Max Load 2 Crank Up Stand ALP6500 Kit W/ Truss Adapter, 440 lbs Max Load 1 Truss Kit, Uprights for Car CEAVCO Order:DEN38771 Printed On:07/16/2015 1.00 350.00 350.00 1.00 75.00 450.00 800.00 1.00 830.00 1.00 0.00 1.00 0.00 1.00 220.00 830.00 0.00 0.00 220.00 Page 2 of 5 1 Dimmer Rack, 24 Channel 20A, Sensor 24 1 Hog USB DMX Super Widget Kit 1 Monitor, LCD 23" 1080P HD w/Pedestal, Kit 1 Laptop, Windows 7, Office 2010, 2.4GHz 8GB RAM 750GB HDD 1 Trunk, Ballroom Rigging Hardware / Denver 3 Lighting kit, Color Blast w/6 CB 12 TR 42 Lighting Kit, ETC Source 4 PARNel w/Clamp 1 Cable, DMX 5 Pin 25' 1 Trunk, Lighting AC 6 CH SOCO Trunk (Denver) 1 Trunk, Cable AC 4 Lighting Kit, ETC Source 4 Complete w/50° Lens 4 Lighting Kit, ETC Source 4 Complete w/36° Lens 4 Lighting Kit, ETC Source 4 Complete w/70° Lens Sub Total Key Lighting and Specials, additional lighting for booths, bars, and attractions 4 Dimmer, Slim Dimmer, 1.8kW Dimmer, LEX 4 Dimmer, Slim Dimmer, 1.8kW Dimmer, With DMX, LEX 12 Light, Source 4, 575 Watt Lamp, w/Stage pin AC 6 Light, Source 4 70° Lens 6 Light, Source 490° Lens 4 Light, Source 4 36° Lens 4 Light, Source 4 19° Lens Sub Total Sponsor Gobo's on tent, 4 in total on tent wall 6 Lighting Kit, ETC Source 4 Complete w/26° Lens 4 Gobo* Sub Total Lighting Discountable Total 35% Discount Lighting Total Video System 3 Screen system for Auction and Imag. Single Camera 3 Christie Roadster HD10K-M 1080 HD 3 Chip DLP Projector 10,000 Lumens 1 Scaffolding, 2 Screen Tower, 4'-10' High w/ Cart 1 Truss Kit, Projector Stand 3 Screen, Draper StageScreen Kit, 9' x 16' Black Frame w/Fabrics (Flown) (16:9) 1 Switcher, HD/SD AW-HS50N Show Kit 2 Laptop, Windows 7, Office 2013, 2.4GHz 8GB RAM 750GB HDD 1 HDSDI Converter, Grass Valley ADVCG1, Kit 1 Camera Kit, DXC-D50WS 1 Presentation, PerfectCue, Cue Light w/2 wireless actuators 6 Tent hanger* Discountable Sub Total 35% Discount Net Amount 1.00 250.00 1.00 125.00 1.00 125.00 1.00 50.00 1.00 0.00 1.00 300.00 1.00 25.00 1.00 0.00 1.00 0.00 1.00 0.00 1.00 25.00 1.00 25.00 1.00 25.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 40.00 40.00 15.00 15.00 ' 15.00 10.00 10.00 1.00 25.00 1.00 95.00 1.00 1200.00 1.00 100.00 1.00 125.00 1.00 300.00 1.00 550.00 1.00 125.00 1.00 150.00 1.00 700.00 1.00 60.00 1.00 75.00 250.00 125.00 125.00 50.00 0.00 900.00 1050.00 0.00 0.00 0.00 100.00 100.00 100.00 3850.00 160.00 160.00 180.00 90.00 90.00 40.00 40.00 760.00 150.00 380.00 530.00 11750.00 (4112.50) 10602.50 3600.00 100.00 125.00 900.00 550.00 250.00 150.00 700.00 60.00 450.00 6435.00 (2252.25) 4632.75 Client to provide security in the building Need lift and generators in place Thursday 8am. Generator Lighting Main 150 kW, Set for 208 operation Generator Lighting Small 60 kW, Set for 208 operation Generator Audio 60 kW, Set for 208 operation CEAVCO Order:DEN38771 Printed On:07/16/2015 Page 3 of 5 JLG E300AJP Electric Boom Lift 1 Truck Ramp, Use for Semi with no dock access Sub Total 1 53' Truck* 1 26' Truck* 2 Travel Expenses, Hotel* Sub Total * indicates non -discountable items Labor 1.00 0.00 1.00 1200.00 1.00 850.00 1.00 150.00 0.00 0.00 1200.00 850.00 300.00 2350.00 Personnel Set up Labor Thursday On -Site Coordinator/Manager, Day Rate* Audio Operator (Al), Day Rate* Lighting Director (LD), Day Rate* Master Electrician* Lighting Operator, Day Rate* Audio -Video Technician, Day Rate* Rigger* Video Engineer* Focus and Rehearsal Friday 5pm - 10pm On -Site Coordinator/Manager, Day Rate* Audio Operator (Al), Day Rate* Lighting Director (LD), Day Rate* Master Electrician* Video Engineer* Show Labor Saturday 1pm - 2 am On -Site Coordinator/Manager, Day Rate* Audio Operator (Al), Day Rate* Audio Operator (A2)* Lighting Director (LD), Day Rate* Master Electrician* Lighting Operator* Video Engineer* Camera Op by cleint Strike Labor Sunday Morning On -Site Coordinator/Manager, Day Rate* Stage Hand* Rigger* CEAVCO Order:DEN38771 Qty Rate RT OT DT Subtotal 1 650.00 1.00 1 550.00 1.00 2 550.00 1.00 2 500.00 1.00 10 475.00 1.00 2 475.00 1.00 3 500.00 1.00 2 550.00 1.00 1 650.00 1.00 1 550.00 1.00 1 550.00 1.00 1 500.00 1.00 1 550.00 1.00 1 650.00 1.00 4.00 1 550.00 1.00 4.00 1 475.00 1.00 4.00 1 550.00 1.00 4.00 1 500.00 1.00 4.00 1 475.00 1.00 4.00 1 550.00 1.00 4.00 1 650.00 1.00 16 475.00 0.50 3 500.00 1.00 650.00 550.00 1100.00 1000.00 4750.00 950.00 1500.00 1100.00 650.00 550.00 550.00 500.00 550.00 1040.00 880.00 760.00 880.00 800.00 760.00 880.00 650.00 3800.00 1500.00 Printed On:07/16/2015 Page 4 of 5 Summary Contract Notes Shipping Comments Equipment Delivery - Shipping Sales & Expenses Labor Damage Waiver Service Charge Discount RLCOLO Sales Tax Order Amount 32501.00 2050.00 300.00 26350.00 0.00 0.00 9737.35 72830 $52,191.95 Your signature indicates that you agree to be bound by all CEAVCO Audio Visual terms and conditions which are available upon request. Payment Terms Clients without an approved Net30 account with CEAVCO Audio Visual must submit payment in full before equipment is picked up or delivered. A 50% deposit is due upon confirmation. Clients with a CEAVCO Audio Visual billable account may pay the remainder within 30 days of invoicing date. Any outstanding balance beyond that date will be subject to a 1.5% per month interest fee. Any open balance after 30 days will void discount offered, and the original balance will be due. Accepted and agreed (Printed Name) Date CEAVCO Order:DEN38771 Printed On:07/16/2015 Page 5 of 5 0 D TD U � • m c 0 U2 • 0 - 0 • 2 03 U o 0 >:,m �y O 0 U O aD PO Box 758 PO Box 758 PO Box 758 Greeley CO 80632 Greeley CO 80632 Greeley CO 80632 RECEIPT DATE g -/p-/5- NO. 88277 RECEIVED FROM (.,Q.11 ah,. 1�ir "I0 NMt/ a A-14. ADDRESS J FOR HOW PAID CASH CHECK /1 C°° •//)L CO MONEY ORDER # d c1z.1457 C BY RECEIPT DATE g -/o-/5 NO. 88278 RECEIVED FROM 0.4Ab, S 0/0 I� L Lo .iL ADDRESS J TU ` e, clAtat 16 lop FOR HOW PAID CASH CHECK A5 /\/V, MONEY ORDER RECEIPT RECEIVED FROM ADDRESS �IA1D 111111dILd..4 &Ad D% $pIo. Itooaa BY DATE 8 -16- /5 - NO. 83279 4'o Al' &4)LA co FOR HOW PAID CASH CHECK L /On WW 133 MONEY ORDER )455- 1455 9 NANCY G CLARK 1820 MONTVIEW BLVD GREELEY, CO 8063 1-522 7 Jig) z s - Pay to the Order of ,� )e ri, Y)) to ( $ .f AL ' +(. %� 7 l Dollars D :on. sal. Do WELLS FARGO C)eid &z, Neils Fargo Bank N.P. olorado wehfapgo.corn For 3 %Q Ynib }?sS Q oiy. NANCY G CLARK 1820 MONTVIEW BLVD GREELEY, CO 80631-5227 Lmi44,2dy 1456 Pb231/6 Date Order ofPay to e S ��. r'P I 1146=00 J ' ' uQ. /a0 Dollars D•r.U. ee B•W. 23-7/1020 2617 9176510551 WELLS Wets A Fargo Bank N 1"ARGO Colorado elhraroo.corn a 813 Alf( 1 Derr r1 For /1 NANCY G CLARK 1820 M0NTVIEW BLVD GREELEY, CO 80631-5227 i For Mach./ ?%% Date 1457 23-7/1020 2617 9176510551 Pay to the WQJ� e^-. Order of L /�i� J/ varn.» o4i I $ 6c o P .�,' Si "Ilea WELLS Eq HGO Wells Fargo Bank N.A. Colorado welhtargo.rom .13 Su e3ool 23-7/1020 2617 9176510551 —I-441er 4A,2k From: Haffner, Gene[mailto:Eugene.Haffner@bannerhealth.com] Sent: Friday, May 29, 2015 10:28 AM To: Wagy, Mitch E Cc: Nancy Clark Subject: ACS Cattle Baron's Ball Thank you for your time on the phone this morning, Mitch. This email is to confirm that the Banner Health North Colorado Medical Center Paramedic Services will be providing dedicated on -site coverage for the 2015 American Cancer Society (ACS) Cattle Baron's Ball. The service will be provided at no charge to ACS. We will receive credit for the in -kind contribution as part of our sponsorship of the event. The event will be held on Saturday, September 19 at the St. Michael's Reservoir Estate of Art Guttersen (65th Ave. south of Hwy. 34 bypass) from 5:30 p.m. — midnight. Nancy Clark of ACS will be your contact to make final arrangements for actual time for the ambulance and crew to arrive on -site. She or the person responsible for site arrangements will be in touch with you. Her contact information is: nancy.clarkcancer.org Nancy Clark I Senior Development Manager, Distinguished Events Great West Division I American Cancer Society, Inc. 8221 W 20th St Suite A Greeley, CO 80634 Phone: 970.350.5019 I Mobile: 970.396.9545 I Fax: 970.356.9238 Please let me know if you need further information or clarification from me. As always, thank you for your commitment, service and dedication to Banner Health and to the community. Thanks, Gene Haffner Director, Public Relations Banner Health North Colorado Medical Center 1801 16th St., Greeley, CO 80631 970-810-6133 office 970-810-6644 fax Banner Health We exist to make a difference in people's lives through excellent patient care 1-2 POBIA BOWL S ft B Porta-Bowl Restrooms, Inc. 3263 Oakland St, Aurora CO 80010 Phone 303-341-6800 FAX 303-341-6828 www.sbprestrooms.com CUSTOMER BILLING ADDRESS: Cattle Barons Ball A FAMILY OWNED COLORADO TRADITION FOR OVER 30 YEARS! DATE: FEBRUARY 12, 2015 EVENT OR SITE NAME: Cattle Barons Ball LOCATION: 3695 65`h Ave, Greeley, CO DELIVERY DATE & TIME: Friday, September 18, 2015 EVENT START TIME: Saturday, September 19, 2015, 5:30P EVENT END TIME: Saturday, September 19, 2015, 1:00A REMOVAL DATE & TIME:Monday, Sep 21, 2015 Restroom Trailer Contract QUANITY DESCRIPTION UNIT PRICE 1 1 4 2 2 Royal Manhattan Restroom Trailer Royal Oasis ADA Just Like Home Restrooms Attendants 12 -Yard Roll -Offs SUB TOTAL: PARTIAL DONATION: TOTAL: $2,995.00 $2,450.00 $1,150.00 Included Donated $7,435.00 $1,725.00 $5,710.00 The Royal Manhattan Restroom Trailer has 4 restroom stalls and 2 hand -wash stations for the women, 2 restroom stalls, 4 urinals and 2 hand -wash -stations for the men. The Royal Oasis Restroom Trailer has 3 restroom stalls and 1 hand -wash station for the women, 1 restroom stall, 3 urinals and 1 hand -wash -station for the men and 1 disabled accessible section with 1 restroom and 1 hand -wash -station. Each Just Like Home Unit has 1 toilet and 1 hand wash station. The price listed includes delivery, collection, set-up and tear -down fees, Tax is not included in this proposal, but customer is responsible for paying all taxes due in connection with any equipment and services ordered. All restroom facilities MUST be placed on level ground (preferably concrete, cement, asphalt or gravel). If the facility is placed in either a sand, grass or dirt area, please be advised that due to possible weather or ground conditions S ft B Porta-Bowl Restrooms will not be held responsible if the ground is damaged. Tie -downs for the trailer may also be required depending on what your jurisdiction requires, customer is responsible for determining whether this service is needed. Tie -down installation and removal are not included in the standard pricing, but can be provided for an additional fee. Tie down installation and removal may also leave holes in the ground, S Et B will not be held liable or responsible for these. We require a minimum of 15' wide to deliver the facilities. Customer is responsible for securing any permits or licenses required for placement. Requirements vary between jurisdictions; we recommend you check with your local city and/or county officials for their requirements. WEDDINGS, GOLF TOURNAMENTS, CORPORATE HOSPITALITY, PRIVATE PARTIES, OUTDOOR EVENTS PHONE 3O3-341-68OO. TOLL FREE 866-893-9OO1. FAX 3O3-341-6828. 2 - The Royal Manhattan will sit 32' long and 15' wide with steps deployed. The Royal Oasis ADA will sit 17' wide and 28' long when ADA ramp is set in place. The ADA ramp also requires an additional 6' in width to accommodate Cif JLH units are 45" long and 42" wide Customer is responsible for ensuring that S & B personnel have sufficient access for delivery, removal and services. This includes adequate snow removal around the trailer for our vehicles. Delivery, collection and any additional waste removal is scheduled during business hours Monday -Friday 8am until 5pm unless otherwise listed on this quotation. Any delivery, collection or waste removal on weekends or holidays, may require additional overtime charges. S Et B will make every effort to deliver, remove or service at scheduled times. S ft B shall not be held liable for delays in performance due to contingencies beyond our reasonable control, including, but not limited to adverse weather, road conditions, strikes, riots, fires and acts of God. Power Needed: Access to main power source within 100' of the facility location as well as three 20 -amp, non-GFI 110 - volt circuits per trailer are necessary. Three standard 3 -prong outlets are required. If no power is available a 7,500 - watt generator for each trailer or a 15,000 -watt for both can be used which must be provided by the customer. Water Needed: Access to a water source with a minimum of 30-50 PSI within 50' of the unit is required. A standard minimum 3/4" garden hose fitting is required for water service to the trailer. If power and/or water is not accessible when the trailer is delivered, an additional trip charge may apply for S & B personnel to come back out to the site and test the power and/or water functionality with the trailer. Liability of Equipment: Customer acknowledges that it has the care, custody and control of Equipment owned and furnished by S ft B and accepts the responsibility therefore except when same is being physically handled by the employees of S & B. Therefore, Customer expressly agrees to defend, indemnify and hold harmless S Et B from and against any and all claims for loss of or damage to property, or injury to or death to person or persons, resulting from or arising in any manner out of Customer's use, operation or possession of any Equipment furnished by S Et B hereunder. Payment: The invoiced amounts based on the pricing listed above will be due with terms of Net 30 days from date of invoice if credit is extended and approved. A 50% non-refundable deposit is due upon booking in order to make a reservation. The remaining amount is due 10 days prior to the delivery date. In the event that the account is not paid according to the terms, the Lessee agrees to pay S Et B a Finance Charge of 1.5% per month on all delinquent amounts. It is also agreed that Lessee will pay S & B all costs of collection, including reasonable attorney fees if incurred on any delinquent amounts owed to S & B. By signing below, you agree that you have read, understand and agree to all of the terms and conditions listed above. Sign Name Print Name Contract prepared by: Carlos Gonzalez Title Date Please note that the pricing above is valid for 30 days from the date listed at the top of this contract and availability is limited. A 50% non- refundable deposit is due upon booking. Full payment must be made 10 days prior to the delivery date. Visa, MasterCard, Discover and AMEX are welcome. WEDDINGS, GOLF TOURNAMENTS, CORPORATE HOSPITALITY, PRIVATE PARTIES, OUTDOOR EVENTS PHONE 303-341-6800. TOLL FREE 866-893-9001. FAX 303-341-6828. Rafaela Martinez From: Nancy Clark [nancy.clark@cancer.org] Sent: Tuesday, August 11, 2015 5:46 AM To: Rafaela Martinez Cc: Nancy Clark Subject: RE: Special Event and Temporary Assembly Permit Applications Cattle Barons Ball Attachments: S & B Combined Contract 2015.pdf; Ambulance Agreement 2015.docx Rafaela — I am attaching both the ambulance agreement and the portalet agreement. I am working on the COI - thank you! Nancy Clark I Senior Development Manager, Distinguished Events Great West Division I American Cancer Society, Inc. 8221 W 20th St Suite A Greeley, CO 80634 Phone: 970.350.5019 I Mobile: 970.396.9545 I Fax: 970.356.9238 cancer.org 11.800.227.2345 THE OFFICIAL SPONSOR OF BIRTHDAYS: BBB. This message (including any attachments) is intended exclusively for the individual to whom it is addressed and may contain proprietary, protected, or confidential information. If you are not the named addressee, you are not authorized to read, print, copy, or disseminate this message or any part of it. If you have received this message in error, please notify the sender immediately. From: Rafaela Martinez[mailto:ramartinez@co.weld.co.us] Sent: Friday, July 24, 2015 11:47 AM To: Nancy Clark Subject: Special Event and Temporary Assembly Permit Applications Good Morning Nancy, Per our phone conversation this morning, attached is the Special Event and Temporary Assembly Applications. Just a reminder that they do need to be submitted to my office at least 30 days prior to the event. 1 Please call or email me with any questions or concerns. Have a lovely weekend! Rafaela A. Martinez Deputy Clerk to the Board 1150 O StreetIP.O. Box 758IGreeley, CO 80632 tel: (970) 336-7215 X5226 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 Rafaela Martinez From: Sent: To: Cc: Subject: Donnie Patch Tuesday, August 11, 2015 3:45 PM Rafaela Martinez Nancy Clark Re: American Cancer Society - Security Agreement The Sheriff's Posse will be providing security for this event. Thank you, Donnie Patch Lieutenant Weld County Sheriff's Office Sent from my iPhone On Aug 11, 2015, at 15:25, Rafaela Martinez <ramartinez@co.weld.co.us>wrote: Good Afternoon Donnie, I am now processing the Temporary Assembly and Special Event Applications for the American Cancer Societies' Annual Cattle Baron's Ball. It is my understanding that the Sheriff's Office will do again this year, as they have done in years past, to provide some type of "Security" for the event. If this is indeed correct, I just need confirmation so that I may add this to their file, as a Security Agreement is required. Thank you and have a wonderful rest of your week! Rafaela a. Martinez Deputy Clerk to the Board 1150 O Street P.O. Box 7581 Greeley, CO 80632 tel: (970) 336-7215 X5226 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. 1 MEMORANDUM To: Rafaela Martinez, Deputy Clerk to the Board August 14, 2015 From: Bethany Pascoe, 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: 3695 65th Ave Greeley, CO 80631 Dates and Time of Event: September 19, 2015 5:30 p.m. to midnight General Information: Zone District: A (Agricultural) No overnight camping shall accompany this Temporary Assembly permit or Special Events permit. 1000 guests + 275 volunteers 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: Tammy Waters, Clerk to the Board DATE: 08/12/15 FROM: Janet Lundquist, 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 1000 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. The roadways adjacent to property are not maintained by Weld County. 5. Please submit an Incident Action Plan for the Office of Emergency Management. Page - 1 - of 1 August 12, 2015 C:\Users\ramartinez\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\BBCGBZMY\Temp Assembly American Cancer Society 2015.doc 139199 i 1 ® A�ORO CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 8/31/2015 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 NAME: Alexander Mortimer PHONE 4O4-923-3732 I FAX 877.362-9069 IA/C, No, Eat): 4O4-923-3732No): E-MAIL ADDRESS: alexander.mortimer@wellsfargo.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Federal Insurance Company 20281 INSURED American Cancer Society, Inc. 250 Williams Street Atlanta, GA 30303 INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : VERAGES CERTIFICATE NUMBER: 9486692 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 TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MMIDDYYY) IY POLICY EXP (MM/DDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY 35943463 09/01/2015 O9/O1/2O16 EACH OCCURRENCE $ 1,000,000 DAMAGE PREM SESO(Ea occurrence) $ 300,000 IRENTED CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 2,500 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 25,000,000 GEN'L X AGGREGATE POLICY OTHER: LIMIT APPLIES PRO JECT PER: L0C PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below YIN NIA I PER - STATUTE I I OTH ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: COIR0000173; Weld County Government; 1150 "O" Street; Event Date: September 19, 2015 Greeley, CO 80634 Certificate of Liability CERTIFICATE HOLDER CANCELLATION Weld County Government 1150 "O" Street Greeley, CO 80634 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(4.,(40110._ The ACORD name and logo are registered marks of ACORD © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) 139199 ACcRO® `.rte CERTIFICATE OF LIABILITY INSURANCE DATE 29/20 IYYYY) 8/29/2014 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 Alexander Mortimer NAME: PHONE 404-923-3732 I FAX 877-362-9069 (AIC. No. Extl: (AIC, No): E-MAIL aexander.mortimer@wellsfargo.com INSURERIS) AFFORDING COVERAGE NAIC # 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: 8109212 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 TYPE OF INSURANCE ADDL INsn SUBR snip POLICY NUMBER POLICY EFF IMM/DDNYYYY) POLICY EXP IMMIDDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY 35943463 9/1/2014 9/112015 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence) $ 300,000 1 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 2,500 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 25,000,000 GEN'L X AGGREGATE POLICY OTHER: LIMIT APPLIES JECT PRO-) PER: LOC PRODUCTS - COMPIOP AGO $ 2.000.000 $ A AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED 73563471 09/01/2014 09/01/2015 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE- $ AGGREGATE $ $ DED [ I RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes describe under DESCRIPTION OF OPERATIONS below YIN N N!A 71741355 09/01/2014 09/01/2015 PER H X T STATUTE I I ER E.L. EACH ACCIDENT 1000 000 S E.L. DISEASE - EA EMPLOYEE S 1,000,000 E.L. DISEASE -POLICY LIMIT 1,000,000 $ DESCRIPTION OF OPERATIONS! LOCATIONS !VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Cattle Barons Ball St Michael's Reservoir 3695 65th Ave Greeley, CO 80634 Event Date: 9/20/14 Setup: 9/11/14 Takedown: 9/25/14 CERTIFICATE HOLDER CANCELLATION Weld County Government 1150 "O" St Greeley, CO 80631 I 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 9L The ACORD name and logo are registered marks of ACORD O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) Rafaela Martinez From: Sent: To: Subject: Lisa Carpenter Wednesday, August 26, 2015 1:50 PM Rafaela Martinez; Lisa Carpenter RE: Special Event and Temporary Assembly Application - American Cancer Society, Inc. To: Weld County Commissioners From: Deputy Lisa Carpenter Date: August 26, 2015 RE: American Cancer Society, Inc. Dear Commissioners, I have researched the calls for service to the American Cancer Society event located at 3695 65th Ave, Greeley, CO 80634. There are no reported calls for service from 2014 through this calendar year. I find no grounds for disapproval for the Special Event and Temporary Assembly Application. Sincerely, Deputy Lisa Carpenter Weld County Sheriffs Office 1950 "O" Street Greeley, CO 80631 970-673-5927 From: Rafaela Martinez Sent: Tuesday, August 11, 2015 3:21 PM To: Dan Joseph; Deb Adamson; Bethany Pascoe; Tom Parko Jr.; Lisa Carpenter; Janet Lundquist; Roy Rudisill; Bob Choate Subject: Special Event and Temporary Assembly Application - American Cancer Society, Inc. Good Afternoon Everyone, In accordance with the procedure for Temporary Assembly and Special Event checks, please review all records on the following document for any associated reports/incidents during the last year and return your report to the Weld County Clerk to the Board's Office within two weeks. Your report will be used by the 1 Board of County Commissioners in considering the Temporary Assembly application and the Special Events Permit. PLEASE RESPOND NO LATER THAN: August 31, 2015 Applicant: American Cancer Society, Inc. File Location: LC0022 Thank you so much and have a wonderful rest of your week? Rafaela A. Martinez Deputy Clerk to the Board 1150 O Street I P.O. Box 758 Greeley, CO 80632 tel: (970) 336-7215 X5226 [cid:image00 1.jpg0 1 DOD449.5643F620] 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 Memorandum TO: Rafaela Martinez FROM: Dan Joseph SUBJECT: Temporary Assembly Application DATE: August 26, 2015 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 3695 65th Avenue, in Greeley, 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 ❑ M u` i. r3 C'1 d J O 6'3a PULL AND RETAIN THIS COPY BEFORE AFFIXING TO THE PACKAGE. NO POUCH NEEDED. O O V C 8 LL{ oe$!112i Lbig 612.ga la 03 a ❑ ❑ rz R 8 8 VO O 1) Address 915 10TH ST 0 ri Hx 0X ❑ ZIP 80631-1117 A City GREELEY 0 G 0 Ir o ,oe TcrEr Y � N 0 0. co N Q' c 0' C 2 U N CD er, or FedEE 3Dey Freight. Phone (30 )0105"o43GU o H c z a E. Deze.g di -eV sa aAa N mm 92m1 o F €a w'm.v. Vag 3,22 CF.- xaB� Be Q 0 VI a U Q 8 2 3 7 Payment Binh): N 0.122 0415722399 Total Declared Valuet E m5 4s lit t-277 Y 0 d N 0 H) E O wU �C a m d 0 Low {fl � N a. 01 ao CO a' t/! e CC0 ▪ dF • E • a >. O O E CIO in Rev. Date b99'Perte1592794h1994-2008 FedEM•PRIN 5709 0956 U.S. Postal Services:, CERTIFIED MAIL,:, RECEIPT (Domestic Mail Only; No Insurance Coverage Provided) Postage Certified Fee Return Receipt Fee (Endorsement Required) O Restricted Delivery Fee a— (Endorsement Required) ru Total Postage & Fees ■ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. • Print your name and address on the reverse so that we can return the card to you. • Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from item 1? ❑ Yes If YES, enter delivery address below: 0 No 1. Article Addressed to: Civia:an- ectAtvti, Sect , c c Cl on : t\leintl C14.A.46 W- a s S A Co $oti).1/ Postmark Here A. S'n ature 0 Agent ❑ Addressee 3. Service Type I Certified Mail° 0 Priority Mail Express'" ❑ Registered ❑ Insured Mail 0 Return Receipt for Merchandise 0 Collect on Delivery 4. Restricted Delivery? (Extra Fee) 0 Yes 2. Article Number (Transfer from service label) 7004 2890 0003 5709 0956 PS Form 3811, July 2013 Domestic Return Receipt Hello