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HomeMy WebLinkAboutpitkin.planning.273718200000 (20)DOCUMENT LAYOUT THIS FILE MAY OR MAY NOT CONTAIN ALL OF THE INFORMATION LISTED BELOW IN THE FOLLOWING ORDER Summary Sheet Resolution for the BOCC and /or P &Z Ordinance for the BOCC and /or P &Z Determination for the Hearing Officer Administrative Determination Staff Memo Application Public Notice, Acceptance Letter, Referral(s) Letter Site Plan Miscellaneous Plat(s) Parcel ID: 2737- 18 -2 -00 -000 Application Date: 6/27/12 Case No: SPE017 -12 Description: Ride Your Heart Out Temporary Commercial Use /Special Event Permit Planner: Mike Kraemer # Copies: Allocated Hours: 3 Project Address: 0 MCLAIN FLATS RD, ASPEN, CO 81611 % Over Hours: 3.6 Property Owner: KASIN Address: 10 PATTERSON DR Owner Phone: (512) 289 -9662 CARBONDALE, CO 81623 Owner's REP: SCOTT KASIN Address: 10 PATTERSON DR REP's Phone: (512) 289 -9662 CARBONDALE, CO 81623 REP's Email: Referrals: ALL OTHER REFERRALS Other Referrals: Comments Due Date: Meetings: 1st Meeting: 2nd Meeting: 3rd Meeting: Meeting Date: Review Body: Public Hearing? Notice Date: Meeting Notes: Approvals: BOCC Resolution #: P &Z Determination #: BOCC Ordinance #: HO Determination #: Admin Determination #: 045 -2012 NR Other Information: VR Approval Date: Plat Recorded Date: VR Expires Date: Plat (Bk, PG): Remarks: Application Type: +r✓ ADMINISTRATIVE DECISION OF THE COMMUNITY DEVELOPMENT DIRECTOR OF PITKIN COUNTY, COLORADO, APPROVING A SPECIAL EVENT PERMIT FOR THE RIDE YOUR HEART OUT BIKE RIDE Administrative Decision No. -2012 RECITALS Pursuant to Subsection 4- 30 -50(i) of the Pitkin County Land Use Code, the Community Development Director of Pitkin County, Colorado ( "Director ") may approve a Permit for special events. 2. The Scott Kasin and MI Aware, Inc. (hereafter, the "Applicants ") have applied to the Director for approval of a Special Event Permit to conduct a bike ride for heart attack prevention on July 3, 2012. Approximately 50 riders are expected to participate. The ride begins in Aspen and travels to the intersection of Hwy 82 /Snowmass Creek Road in Old Snowmass via McLain Flats Road, Upper River Road, and Lower River Road. An aid station is proposed at the Old Snowmass Conoco. Approximately 25 riders will return to Aspen using the same route. 25 riders will continue riding using the Rio Grande Trail to Emma. From Emma, riders will continue along Sopris Creek Road, to East Sopris Road, to Snowmass Creek Road (dirt road turnaround), to Capitol Creek Road (Monastery turnaround), return to Old Snowmass Conoco, cross Hwy 82, and return to Aspen via Lower River Road, Upper River Road, McLain Flats Road. 3. The Pitkin County Sheriffs Office, the Aspen Fire Department, Basalt and Rural Fire Department, Aspen Ambulance District, Communications, and the Emergency Manager have all commented on this event. Given its small size all entities supported the proposal with no conditions. Pitkin County Open Space and Trails has issued a permit for use of the Rio Grande Trail. 4. The Applicants have provided a Certificate of Insurance covering this event and naming the County as an Additional Insured, satisfactory to the requirements of the Risk Manager. The Applicant has provided consent from the owner of the Snowmass Conoco to use the property. The Director finds that, to the extent applicable, the application complies with the standards in Subsection 4- 30 -50(i) of the Land Use Code. THE DIRECTOR HEREBY APPROVES the Special Event Permit for the Ride Your Heart Out Bike Ride subject to Applicant's compliance with each of the following conditions: 1. The Applicants shall adhere to all material representations made in, or in connection with, the application. 2. No emergency access shall be blocked. 3. On County Roads, riders shall ride single file when traffic approaches. 4. Failure to comply with the conditions of approval may result in revocation of this permit. Page I of 2 w` APPROVED thi day of , 2012. L� ndy Houben Community Development Director SP017 -12 PID# 273718200000 ,acoRO® CERTIFICATE OF LIABILITY INSURANCE ° "114/2012 05!1412012 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($), 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 HOME CT Scott Kasin PHONE FAX AIC No : Andrew Shivetts E4 aIL : 1 Bala Plaza, Suite 100 INSURERS AFFORDING COVERAGE NAIC N Bala Cynwyd, PA 19004 INSURERA: Philadelphia Indemnity Insurance Companies 10853 MED EXP (Any one person) INSURED MI Aware, Inc. INSURER B : $ 1000000 10 Patterson Dr. INSURER C: GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC PRODUCTS - COMP /OP AGG S ()0 Carbondale, CO 81623 INSURER D: Al1TOMOBRE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON-OWNED HIRED AUTOS AUTOS �; F INSURER E: INSURER F: COMBINED SINGLE LIMIT Ea acddent S COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 NTH 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS, INSR LTR TYPE OF INSURANCE A DL SU POLICY NUMBER POLICY EFF POLICY EXP LIMITS GENE RALLIABILITY COMMERCtAL GENERAL LIABILITY CLAIMS -MADE X OCCUR F r I 6280840 07103/2012 07/04/2012 EACHOCCURRENCE 5 1000000 DAMAGE TO RM9TPU- PREMISES (Ea occurrence $ 100000 MED EXP (Any one person) $ 0 PERSONAL & ADV INJURY $ 1000000 GENERAL AGGREGATE S 3000000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC PRODUCTS - COMP /OP AGG S ()0 s Al1TOMOBRE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON-OWNED HIRED AUTOS AUTOS �; F COMBINED SINGLE LIMIT Ea acddent S BODILY INJURY (Per person) $ BODILY INJURY (Per aatidenl) S PROPERTY DAMAGE Per accident S S UMBRELLA LIAO EXCESS LIAR HCLAIMS-MADE OCCUR I EACHOCCURRENCE 5 AGGREGATE 5 DIED RETENTIONS $ WORKERSCOMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN OFFICEIMEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA WCSTATU• OTH- E L. EACH ACCIDENT S El. DISEASE • EA EMPLOYEE S El. DISEASE • POLICY LIMIT $ r I r I DESCRIPTION OF OPERATIONS! LOCATIONS 1 VEHICLES (Attach ACORD 101, Additlonal Remarks Schedule, Tf more space Is required) Pitkin County 130 S. Galena St. Aspen, CO 81611 ACORD 25 (2010105) I,fl L"MV Lei 9!LA_II Lei 9, 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 ©1988 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Ride Your Heart Out Ride Your Heart Out friendly view. Tuesday, July 3, 2012 Primary Jurisdiction: Pitkin County Overall Status: Not Yet Reviewed Event Category: City of Aspen - Town of Snowmass Village - Pitkin County Special Event On -line Application Click HERE if you'd like to view the entire on -line application. Page 1 of 5 Click HERE for a printer Specific location(s): Start and finish in City of Aspen at Gondola Plaza or other private property. It will travel down Durant to Hopkins to Cemetery Ln/McClain Flats. Pass through Woody Creek on Upper/Lower River Rds to Old Snowmass. The 50km ride will turn around there and travel back the same way. 100km route will continue down valley on Rio Grande to Emma. Pick up East Sopris Creek to Snowmass Creek to the Dirt (turn around) and head back down to Capital Creek Rd and up to the Monastery before turning around and traveling back to Conoco Station off Snowmass Creek Rd and back to Aspen via River Rds, McClain Flats to Cemetery Ln bike path to Hopkins bike way to Durant. DATES/TIMES: Set -up: 07/03/2012 06:00 AM Start: 07/03/2012 09:00 AM End: 07/03/2012 02:00 PM Dismantle: 07/03/2012 03:00 PM PRIMARY CONTACT: Scott Kasin Send e -mail MI Aware, Inc. 10 Patterson Dr. Carbondale, CO 81623 Phone: (512) 289 -9662 Fax: (970) 963 -4983 Work: (512) 289 -9662 OTHER CONTACTS: During event - contact names & phone numbers Primary: Scott Kasin (512) 289 -9662 Secondary: Lisa Kasin (512) 619 -5472 Medical: Rob Bordan (970) 948 -1805 Parking: Dylan Johns (970) 948 -6787 QPbWl Rob Bord an (970) 948 -1805 d a l http:// specialevents .aspenpitkin.comldetails.cfin ?printviewflag =l &eventid =660 6/25/2012 Page 2 of 5 Security: Scott Kasin (512) 289 -9662 Transportation: Dylan Johns (970) 948 -6787 DETAILS & DOCUMENTS: Event Summary: MI Aware's 4th annual Ride Your Heart Out to raise awareness for heart attack prevention. MI Aware is a registered Colorado non - profit founded by Scott Kasin whose 4th anniversary of his heart attack is July 3rd. As we've been doing a social ride for the past 3 years from various businesses (Hub of Aspen, and Paradise Bakery), we expect between 30 - 50 people for the ride with approximately 1/3 doing the shorter out and back ride, and the remainder doing some portion of the longer loop including Emma and Snowmass. We're all volunteers and there is no required fee or donation to participate. We plan to maintain a 5 to 1 ratio of ride leaders / chaperones to participants. We'll have one aid station at the Old Snowmass Conoco with two volunteers, energy bars, water and restrooms. Since the ride is 4th of July weekend, many of our usual riding friends are out of town racing and/or vacationing with family which limits are participation. Additionally, we limit participation through our choice of roads as most people are not interested in riding the route we've selected. Many of our participants are trained in first aid, and will have at least one emergency doctor on the ride. Our ride leaders are all trained by myKatalyst in safety and practical guiding safety principles. Many of our ride leaders are licensed competitive racers, triathletes, and ski professionals with training in group handling and safety. There will be no amplified music, and no parry afterwards. The only food served will be energy bars and fruit for the participants as well as water jugs. Since the majority of the ride will be within cell phone range utilizing multiple cell phone carriers will be sufficient for call 911 if needed. In the event we do not have coverage, we have arranged for a handheld radio to relay the call for help. Final MI Aware_lowres.pdf Ride Your Heart Out 100Km.pdf 695.19 k The story of MI Aware for back ground. 2.38 Megs Ride Your Heart Out 100Km - Long Route Ride _Your_Heart_Out_2012_50Km.pdf 1.97 Megs Ride Your Heart Out 50Km - Short Route Site Plan (and maps): The registration gathering will take place on the Gondola plaza.. There will be a 10 x 10 pop up tent with a small table for participants to sign waivers. Communication Plan: Public information and service announcements will be broadcast through neighborhood letters, and signage will inform community members to be aware of riders on the road as well as riders coming through particular neighborhoods. We will also use stakes to mark the two courses with safety signs (ex . caution, riders on road), as well as volunteer course marshals at major intersections will direct riders /community members safely. The route we've chosen is fully accessible with cell phone service and radios are not deemed necessary. In the event we are going to need a radio Steve Goldenburg 000002 http: / /specialevents .aspenpitkin.com /details.cfm ?printviewflag =l &eventid =660 6/25/2012 Page 3 of 5 of the local ham radio club has offered to make himself available in any dead spots to relay for help. Security Plan: We don't believe security will be necessary as we'll have direct access out of town with no traffic lights or crossing main thorough fares. Additionally, the size of our group is not expected to exceed 50 people, and we are not leaving any personal property where security might be needed. Medical Plan: Our medical plan includes multiple doctors, emts, and first aid certified participants who can act on the scene until first responder help arrives. Firs aid kit will travel with lead group of riders on the large route, and be available at the aid station in Old Snowmass. Dr. Jon Gibans will be on site and available. Contact info is 970 - 379 -0883 jgibans @comcast.net Ambulance / transport accessibility is within 10 min at any segment of the course. ' Local service providers will be notified of the event in case of emergencies so that they are aware of us on July 3. Safety Plan: Medical support will be provided at the Aid station in Old Snowmass. It will be located on private property with approval of Bill Welcher, owner Snowmass Automotive. The route will be inspected and swept for debris the day before the event by volunteers and hazards will be marked with signage and chalk. Participants will sign a waiver which specifically calls out their agreement to follow ALL rules of the road. And finally during the mandatory pre -ride meeting at 8:45 am, riders will be reminded of the rules of the road with an emphasis on the social aspect to this ride, and any hazards that are discovered from the evening before. MI Aware Waiver.pdf 467.82 k Transportation/Traffic Plan: Our route has been carefully chosen minimize risk and traffic impact. We will not require any, "No Parking ", "Cones ", or "Barricades ". We do not require any professional street cleaning as the route is a well maintained combination of city streets, bike way, county road, and bike path. Our ride committee will inspect, mark and sweep any hazardous sections of the course the day before the event, and remove any signage placed on course the evening after the ride. Parking Plan: There will be no parking on -site and all local participants will be encouraged to ride their bikes to the start of the event. Sanitation/Recycling Plan: 000003 http: // specialevents. aspenpitkin .com /details.cfm ?printviewflag =l &eventid =660 6/25/2012 Page 4 of 5 At the Gondola plaza garbage receptacles and recycling facilities are already in place. We do not expect a lot of refuse as the only food being supplied are bananas, oranges, and energy bars. Alcohol Mitigation Plan: No Alcohol to be served. Accessibility Plan: The start venue is fully accessible with restrooms, water, and we will provide fruit and energy bars for the participants to eat. Alcohol Permit & License: N/A Food Permit: N /A, as the only food served will be fruit and energy bars. Parks /Open Space Permit: As we don't plan to use any of the local parks, and will be staying on roads, it seems any parks and rec permits are N /A. Reviewed and accepted: YES Sales Tax & Bus. License: N /A, as nothing will be sold at the event. Reviewed and accepted: YES Miscellaneous Permits: N/A Liability Insurance: We are getting a quote through Philadelphia Insurance Co for a 1 day event insurance and will have something in place prior to the event which meets guidelines. See application attached, awaiting underwriter approval. PHLY Special Event App.pdf 646.58 k Liability insurance application naming City of Aspen, Pitkin County, and Aspen Skiing Company as additionally insured. References: Ride for the Cure - Ride Committee - 2011, 2012 Mark Alderdice - 970 - 309 -6532 Nancy Pickard 970 - 306 -5955 Logan Hood 970 - 379 -0781 MI Aware Ride Your Heart Out social rides - 2009 - 2011 Rob Bordan - 970 - 948 -1905 Dylan Johns - 970 - 948 -6787 LAF - Ride for the Roses pre -rides - Guided cancer survivors safely as a member of Team Lucky Lounge and Six in Austin, TX http:// specialevents .aspenpitkin.com/details.cftn ?printviewflag =l &eventid =660 6/25/2012 PHILADELPHIA C- E a lo o z ' u, I t e I( "0 INSURANCE COMPANIES QA !',_,°004 . .. . ...... . .. . . . ........ . SPECIAL EVENT SUPPLEMENTAL APPLICATION F - - - -- ----- SUBMISSION REQUIREMENTS • Currently valued insurance company loss runs for the current policy period plus three (3) prior years (for accounts where premium exceeds $5,000.) • Copy of rental agreement or contract to rent or use venue • Athletic Events- Complete the Amateur Sports Special Events Supplemental Application . ...... . .. --- A—CCO! NTIWF0­RM_A_Tt0N — ___ ------- j Applicant Name. MI Aware, Inc- Address: 10 Patterson Dr. E-mail Address: AskEagsaiet,&RMMI!agmwgarme.or-q Web site: www. Mlaware-oro Phone:..512-289-9662 .......... Contact person (Billing): Scott Kasin Phone: 512-289-9662.. Contact person (Loss Control)- Scott Kasin Effective dates requested: ...713112 Event gross revenue: $ 0 — ❑ For Profit ❑ Individual ❑ Partnership ❑ Association F-1 Corporation 0 Non Profit F1 Omer: Years this entity in business: 3 Years experience of this owner. 7 1. Has the Applicant had any claims filed against it in the last four (4) years? ❑ Yes ❑ No If yes, please provide details: 2. Description of event: 501(m / 100 Krn social bike ride for 30 - 50 people on city of Aspen and Pitkin County Roads and Bicycle Paths. it is to promote heart attack awareness and prevention and is the 4th year in existence. 3. Date(s): 7/3/12 Times: 7 am set up, 9 am ride start, 2 pm all riders finished .3 Urn tear dowa.2om late.. (Attach brochure or promotional materials if applicable.) Total number of attendees: 3_0 - 50 Total number of volunteers: 10 Revenue generated: Admission fees Liquors sales Food sales Merchandise Number of attendees per day: Number of volunteer's per day: $ 0 $ 0 $ 0 $ 0 Special Event Supplemental Page I of 5 Application a Is alcohol being served? If yes, by whom? Has server provided evidence of liquor liability insurance? Is Liquor Liability coverage desired? If yes, complete Liquor Liability Supplemental. ❑ Yes ❑ IN o Yes LJ No Yes ONo 5. Name of Venue: Aspen Skiin<1 Cam an Gondola Plaza Address of Venue: 520 East Durant Avenue As CO 81611 Seating capacity: 0 . . .... r signature Seating type: (permanent grandstands, temporary bleacher) Plaza for staging and waive Number of exhibitors: 6. Who is providing security at venue? None required paint for ride., if private firm, they must have insurance and name you as an Additional Insured. Describe the safeguards in place to prevent injury to spectators: 5escribi first aid/medical arrangements: Multiple first aid certified, first responder, and emergency medical doctors will be participating in event and available throughout ride. 911 is available to dispatch ambulance in need. 7. Is the event limited to venue grounds? No if no, provide details: No the event will include a number of city, and county roads and bicycle paths. 8. Swimming: If yes, are certified lifeguards on duty) Are they CPR trained? Are certificates received by insured? 1771 Yes 0 No ❑ Yes ❑ No 171 Yes ❑ No 171 Yes ❑ No 9. is the Applicant required to provide certificates of insurance to any other entity? ❑ yes ❑ No if yes, are you required to name that entity as additional insured? yes 171 No It yes, provide the names of all certificate holders and additional insured along with their interest. City of Aspen Pitkin County Aspen Skiing Company, Inc Special Event Supplemental Application Page 2 of 5 04/2010 10. Are any of the following present at the event? Amusement rides Animal rides Balloon rides Circus Climbing Walls Demolition Derbies Fireworks Food Vendors Haunted Houses Hay rides Inflatables (bounce houses, etc.) Petting Zoos Tractor Pulls if yes, please describe: 11. Other comments: FRAUD NOTICE STATEMENTS ❑ Yes 0 No ❑ Yes ❑✓ No ❑ Yes No ❑ Yes No ❑ Yes r71 No ❑ Yes ✓❑ No ❑ Yes 0 No ❑ Yes ❑✓ No ❑ Yes 0 No ❑ Yes No ❑ Yes 0 No ❑ Yes No ❑ Yes No NOTICE TO APPLICANTS: "ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION. OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.' NOTICE TO ALASKA RESIDENTS APPLICANTS: A PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE AN INSURANCE COMPANY FILES A CLAIM CONTAINING FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE PROSECUTED UNDER STATE LAIN." NOTICE TO ARKANSAS RESIDENT APPLICANTS= "ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR APPLICATION ON FO INSURANCE ES OF GUILTY OF A CRIMNE AND MAY BE I SUBJECT TO FINS AND CONFINEMENT IN PRISON." NOTICE TO ARIZONA RESIDENTS APPLICANTS: "FOR YOUR PROTECTION ARIZONA LAW REQUIRES THE FOLLOWING STATEMENT TO APPEAR ON THIS FORM. ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES' NOTICE TO COLORADO RESIDENTS APPLICANTS: "IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL. OF INSURANCE. AND CIVIL PROVIDES ALSFGINCOMPLETE, OR MN SLEADING FACTS OR INFORMATION TO POLICYHOLDER OR CLAIMANT FOR THE PURPOSE. OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.- Special Event Supplemental Page 3 of 5 04l2010 Application NOTICE TO SC UBIPU NI CRIME INSURER PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE OR ANY OTHER PERSON. PENALTIES INCLUDE FALSE INFORMATION IMPRISONMENT MATERIALLY RELATED ADDITION, AN INSURER MAY DENY TO BENEFITS IF O A CLAIM WAS PROVIDED BY THE APPLICANT,' NOTICE TO FLORIDA RESIDENTS APPLICANTS: "ANY PERSON WHO. KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE." NOTICE TO KENTUCKY APPLICANTS: "ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY "MATERIALLY" FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO. COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME.' NOTICE TO LOUISIANA RESIDENTS APPLICANTS: "ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON' NOTICE TO MAINE RESIDENTS APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO N INSURANCE COMPANY FOR THE PURPOSE.. OF DEFRAUDING THE COMPANY PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.` RESIDENTS OF MARYLAND APPLICANTS: "ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR NF F PAYMENT BENEFIT O K O2MA7ON IN ANAPP ICATIONFOR INSURANCEIS GUILTY OFAC A CRIME AND MAY BIESUBJECT TO FINES AND CONFINEMENT IN PRISON." IS FACILITATING A FRAUD AGAINST APPLICANTS: NY INSURER, SUBMITS HN APPLICATION OR FILES A CLAIM CONTAINING NG A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD_" ON RESIDENTS N APPLICATION FOR AN INNSSURANCEE POLICY PERSON IS INCLUDES ANY FALSE AND CIVIL PENALTIES' LADNG INFORMATION RESIDENTS OF NEW MEXICO APPLICANTS: "ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY FOR INSURANCE S GUILTY OFF A CRIME AND MAY BE SUBJECT TO CIVIL PENALTIES,* APPLICATION FINES AND CRIMINAL RESIDENTS OF NEW YORK APPLICANTS: 'ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING. CRIME ANDOSHALL ALSO BE ANY BJECT TO MATERIAL IVI PENALTY NOTMTOSEXCEEDF IVENTHOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION." RESIDENTS OF OHIO APPLICANTS: 'ANY PERSON WHO. WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST ANY INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD' RESIDENTS OF OKLAHOMA APPLICANTS: -ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE. DEFRAUD OR DE CEIVE ANY LETS INSURER, MISLEAD MAKES ANY CLAIM/ FOR THE S GUILTY OF A DDS OF A INSURANCE POLICY CONTAINING ANY RESIDENTS OF OREGON APPLICANTS: "ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD OR SOLICIT ANOTHER To EFRAAUDTO AN ANY MATERIAL (1 FACTUBMI TI VIOLATING APPLICATION, , OWR. (2} BY FILING A CLAIM CONTAINING A INSURRANCEO COMPANY YOR OTHER PIERSON FILLEES AN APPLICATTIONO FOR GINSURANCE ORTSTATEMEN DEFRAUD CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES." RESIDENTS OF TENNESSEE APPLICANTS: "IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING t INCLUDE IMPRISONMENT, ATT O FINES AND DENIAL OF INSURANCE BENEFITS,- PURPOSE OF DEFRAUDING THE COMPANY Page 4 of 5 04/2010 Special Event Supplemental Pa 9 Application RESIDENTS OF TEXAS APPLICANTS: IF A LIFE, HEALTH AND ACCIDENT INSURER PROVIDES A CLAIM FORM FOR A PERSON TO USE TO MAKE A CLAIM, THAT FORM MUST CONTAIN THE FOLLOWING STATEMENT OR A SUBSTANTIALLY SIMILAR STATEMENT: "ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON." RESIDENTS TOR ANN INSURANCAPPLICANTS: Ot'�+tPANY CRIME TO KNOWINGLY PURPOSE OF PROVIDE FALSE, THE COMPANY. P OR MISLEADING ENALTIES M Y INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS' RESIDENTS OF WASHINGTON APPLICANTS: "IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE. OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSES OF DEFRAUDING THE COMPANY, PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS" RESIDENTS OF WEST VIRGINIA APPLICANTS: "ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.' � / /L //� Insured Signature Date Dirctor, MI Aware Inc Title Producer Signature Date Special Event Supplemental Page 5 of 5 04/2010 Application 000009 t 'f t 0 U 0) N N O M c i CO ti M M M O O L�J L °o L � o o" O a NN a ■ to ouo( s ma G Q��6 )io i i i i i i i i i 0 i i -P6 E a m E - c � E 8u°' o dv oao 5 �. to age E iT m tl- 0 T- Q) O M CL �7= ►4 Q T �F+ L 2II O O a d a c,joi 11 f o•v��° y0v i ivE= vy a m ms's n a � d i >� a d a N w N m a Z N .L O c to -0, U Om U to > v O O O O U O i "a p J UM p � a p Z o ma Q 3 3 � C O a V C o p 3 M N Q N C O O = m O 1 OY L O N .y d = Od y r. d L 07 .. d. e+ C d L p t. im a1a a OQ' d 3 a) FEN, E hc m cR EQ E3 a m E c3M�0 sm` �_ME z!.Fa H 2U f-d H7 H U) Y (- HJ Mw U V5M U) 2 W o co ce) r- Cl) r'. o Er m Ern � EN � U. 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Inc. (A Registered Colorado Non- Profrrl Waiver and Release of Liability Form In consideration of being allowed to participate in anyway in the activities of MI Aware, Inc. and/or Katalyst Performance Consulting, Inc., the undersigned acknowledges and agrees that: 1) The risk of injury from the activities involved, is significant, including the potential for permanent paralysis and death, and while particular rules, equipment, and personal discipline may reduce the risk, the risk of serious injury does exist; and, 2) I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCES OF THE RELEASEES or others, and assume full responsibility for my participation; and, 3) I willingly agree to comply with the stated and customary terms including but not limited to following all rules of the road and conditions for participation. If however I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and, 4) I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS MI Aware, Inc., their directors, coaches, volunteers, and/or employees, and, if applicable, leasers of the premises, WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. X (participant's signature) Date FOR PARTICIPANTS OF MINORITY AGE (under 18 at time of registration) This is to certify that I, as a parent /guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees. And, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify the Releasees from any and all liabilities incident to my minor child's involvement or participation in these programs as provided above. X (participants /guardian's signature) Date X (emergency phone number) U0021 PITKIN COUNTY COMMUNITY DEVELOPMENT Permit Receipt RECEIPT NUMBER 00032647 Name: Mi Aware Date:7/3/2012 Project Address: 0 MCLAIN FLATS RD Type: check # 104 Permit Number Fee Description Amount 0017.2012.PSPE PP- Special Event Flat Fee 312.00 0017.2012.PSPE PP- Clerk Tech Fee 25.00 Total: 337.00