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[Extraction: OCR (rendered-page OCR)]
CITY OF WEST CHICAGO
CITY COUNCIL
AGENDA ITEM SUMMARY
ITEM TITLE:
AGENDA ITEM NUMBER: TA.
Homecoming Fireworks
West Chicago Community High School FILE NUMBER:
District 94
COMMITTEE AGENDA DATE: N/A
COUNCIL AGENDA DATE: October 7, 2024
STAFF REVIEW: Tom Dabareiner SIGNATURE_/ z=
APPROVED BY CITY ADMINISTRATOR:
Michael Guttman SIGNATURE
ITEM SUMMARY:
West Chicago Community High School District 94 is seeking approval for a brief, less than five-minute,
firework show to the attendees of the high school football game scheduled for Friday, October 18, 2024.
This is to help celebrate the 50 anniversary of the West Chicago Wildcats Football team winning the
state championship in 1974.
The Special Event Permit Application has been reviewed and approved by staff from the Police, Public
Works, and Community Development Departments as well as the West Chicago Fire Protection District.
A Fireworks Permit is in the process of being secured through the West Chicago Fire Protection District.
Insurance documentation has been reviewed and approved.
ACTIONS PROPOSED:
Recommend event for approval, contingent upon receipt of an approved Fireworks Permit from the West
Chicago Fire Protection District.
COMMITTEE RECOMMENDATION:
Going straight to City Council due to time constraints.

===== PDF PAGE 41 =====
[Extraction: OCR (rendered-page OCR)]
City of West Chicago
SPECIAL EVENT PERMIT APPLICATION
THIS FORM MUST BE COMPLETED IN FULL & SUBMITTED
90 DAYS PRIOR TO THE EVENT
PERMIT NO.
| Special Event Permit Application
The Special Event Application must be submitted to the City of West Chicago a minimum
of ninety (90) days prior to the event if it requires closure of public streets, or use of public
parking lots and/or city personnel. The 90-day time period allows sufficient time to evaluate
the request and provide a recommendation to the City Council for its consideration. For
any late submittals (applications submitted less than 90 days prior to the event), a $50 late
fee must be paid with the application. Further, the applicant runs the risk of their Special
Event request being denied.
Note: Prior to review of the Special Events Permit Application, all applicants must
| submit the Intent to Meet Insurance Requirements form (page 2).
Submittal Checklist
1. Completed and signed Special Event Application
a Intent to Meet Insurance Requirements
a Section 1 — General Information
a Section 2 — Narrative
a Section 3 — Permits
a Section 4 — Site Plan and/or Route Map
a Section 5 — Task List and Due Dates
ao Section 6 — Hold Harmless Agreement
2. Completed and signed applications(s) for other permits(s) (See Section 3)
a Carnival Permit Application - $50 per employee
a Fireworks Permit Application —
$125 (Check made payable to the West Chicago Fire Protection District)
0 Building Permit Application (temporary tents — see min. requirements) - $50
a Raffle Registration Application — requires separate application
a Temporary Liquor License Application — requires separate application
a Temporary Food Service Permit (DuPage Co. Health Dept. 630-682-7979)
FEI III IIT III IIT IIIT III IAAT TOTTI TIT I IIIT IIIT ITSO TIO IATA ITAA I AOI AAI OS SIA.
FOR OFFICE USE ONLY
RARER IIR IR III IIIA I IAI IIIS III ISIS I IIIS III IIASA IIIT IISA IIIS ISI IIASA IIIA IOI ISAS IIIS SISOS SII IASI ITSO SISOS SIO.
Received: q | 24] 24. Fee Paid: $_ SO \pie fee
Receipt # —_ Check # ePay 4 [27
Event Acknowledgement Form returned by:
Police Dept. Fire Dist. PW Park Dist. CDD
a Background checks completed by Police Dept. Date
a DuPage Co. Health Department notified Date
a Certificate of Insurance received and approved Date
Page 1 of 8

===== PDF PAGE 42 =====
[Extraction: OCR (rendered-page OCR)]
** INTENT TO MEET INSURANCE REQUIREMENTS ***
Must be returned prior to application review by City staff
Prior to the issuance of a Special Event Permit, all organizations must
present a certificate of insurance meeting the criteria listed below:
1. Required limits per IML-RMA are $1mil per occurrence and general aggregate no less than
$2mil for contractors/vendors.
2. *“PLEASE NOTE: Under the box labeled “Description of
operations/locations/vehicles/exclusions added by endorsement/special provisions”, the
following language must appear:
“The City of West Chicago, its officials, agents, employees, and volunteers is/are named
additionally insured. The additional insured is covered as respect to liability arising out of any
work or activities performed on behalf of (company involved) for (event) (date, times (if
applicable), location) No endorsements or additional forms modify or limit coverage provided
to additional insured. Coverage provided to additional insured is primary as it relates to
(event)’.
3. Vendors shall furnish the additional insured endorsement (consult insurance professional;
examples include but are not limited to forms CG 2010 or CG 2026) to support the certificate
of insurance. The endorsement shall also name “The City of West Chicago, its officials,
agents, employees, and volunteers” as primary and non-contributory.
4. lf applicable, vendor shall furnish the City with evidence of Worker's Compensation
coverage with statutory limits.
5. The insurance provider will need to submit the Certificate of Insurance and supporting
endorsement form preferably via email to specialevents@westchicago.org or fax
(630-293-1257) to be considered an original document.
1, Nice Por representing Wek Chai Schoo!
(print name o} ef autiomed person) (organization)
have contacted the appropriate insurance provider and acknowledge that the above
insurance criteria can be met. | understand that the Special Event Permit Application
will not be reviewed until this document has been signed and returned to the City of
West Chicago.
4 23/2
(signature) (date)
West Cogs Wigh Sooo Powecovmin wo/lO [e+
(name sae (date of event)
Page 2 of 8

===== PDF PAGE 43 =====
[Extraction: OCR (rendered-page OCR)]
SECTION 1 —- GENERAL INFORMATION
Name of Event: __ wes Crwiceto Heweromiinc Ercewor&
Type of Event:
O Parade O Walk/Run/Bike © Carnivals & Fireworks O Festival
0 Other
Location of Event: UDesk Chricergcr Wich Sclnco \
Date(s) of Event: 10/1/24 Hours of Event: $00 Pp to G00 p Est. Attendance: 2000
Event Website: __Ududu00, $44. ORG
Purpose of event: Celebrate. lovretomies and 6O™ Ansiverscry of Stele of &
TTiWe.
Name of Sponsoring Organization(s):_LOest Owicego Wila School
Organization's Legal Status (i.e. NFP, Partnership, Corporation):
Contact person from sponsoring organization: Nae Rossy
Organizer address: Wk. Sk.
City/State/Zip: i » TL. wolos Phone: @0-O16- Gow
Cell Phone |_ E-mail: N@APRY@ H44.0RG |
Emergency contact information (provide mobile numbers for on-site coordinators during event):
1° Contact: Wiel Rory Phone:
2"? Contact: Orittouny. Aboats\us Phone:
Is this an annual event? O Yes [No if Yes, provide next year’s event date:
If the event is a recurring event, please state any problems and/or incidents that have occurred in past
years, such as noise or neighborhood parking complaints.
What, if anything, are you doing to rectify the problem(s)?
SECTION 2 ~ NARRATIVE
On a separate sheet, provide a detailed description of the overall event. The narrative will serve as
the special event proposal to City Council.
Page 3 of 8

===== PDF PAGE 44 =====
[Extraction: OCR (rendered-page OCR)]
The West Chicago High School Athletic Department would like to provide a brief (less
than 5 minutes) fireworks show to the attendees of the high school football game on 10/18/24.
This game marks our annual Homecoming football game and is also a celebration of the 50th
Anniversary of the West Chicago Wildcats Football team winning the state championship in
1974. This show will take place between the hours of 8:00 PM and 9:00 PM during the halftime
of the the football game. It will last approximately 5 minutes in duration.
The purpose of this show is to celebrate the great history of the high school football team
and their accomplishments 50 years ago.

===== PDF PAGE 45 =====
[Extraction: OCR (rendered-page OCR)]
SECTION 3 — PERMITS
Will your event include a carnival? oYes No
If yes, you must submit a Carnival Permit Application ninety (90) days prior to the event.
Please visit www.westchicago.org under Forms for an application.
Does your event include the use of a temporary tent in excess of 400 sq. ft. in area with side curtains
or 700 sq. ft. in area without side curtains? o Yes No
ff yes, you must submit a Building Permit Application thirty (30) days prior to the event.
Please visit www.westchicago.org under Forms for an application.
Will your event include a fireworks display? a Yes oNo
if yes, you must submit a Fireworks Permit Application thirty (30) days prior to the event.
Please visit www.westchicago.org under Forms for an application.
Are you holding a raffle at your event? o Yes pNo
if yes, you must submit a Raffle Registration Application fourteen (14) days prior to the
event. Not aif applicants will qualify for a license. Please visit www.westchicago.org under
Forms or contact the City of West Chicago at (630) 293-2200 ext.170 for an application.
Will you be applying for a Temporary Liquor License? «Yes ywNo
If yes, you must submit a Temporary Liquor License Application thirty (30) days prior to the
event. To qualify for a Class D license, the applicant must be a local organization or group
providing beer and/or wine at a picnic, carnival or similar function. A Class D license shall be
authorized on a day-to-day basis but not for more than seven (7) consecutive days. Please
contact the City of West Chicago at (630) 293-2200 ext. 170 for an application.
Will you be serving food at your event? oa Yes No
if yes, you may be required to submit a Temporary Food Service Permit Application thirty
(30) days prior to the event. Please contact the DuPage County Health Department at (630)
682-7979 or visit htte:/www.dupagehealth.orgtemporary-food-service for additional
information.
Are you requesting services from these departments?
& Police & Fire District / Paramedics © Public Works
Specify services: Police and Posamedicy Gre ONE Snedred bo
De Were
Will you be utilizing any of the following services?
Cl] Water 1 Electric/Generator O Other
Page 4 of 8

===== PDF PAGE 46 =====
[Extraction: OCR (rendered-page OCR)]
SECTION 4 — SITE PLAN AND/OR ROUTE MAP
Please attach a separate sheet to illustrate the layout for your event.
'f applicable, the following must be included:
Location of garbage receptacles (G) Location and number of barricades (B)
Location of toilets (T) Location of fire lane (FL)
Location of hand washing sinks (HWS) Location of fire extinguishers (FE)
Location of retail vendors (RV) Public entrances and exits (PE)
Location of food vendors (FV) Location of “No Firearms” signage (NF)
Location of first aid (FA) Location of sound stages and amplified sound (S)
Location of residential streets surrounding event
Are you requesting the use of any City-owned property, i.e. City streets, parking lots, or sidewalks?
(1 Yes & No if yes, please indicate the property that you are requesting to use.
Would you like to request the closing of City streets? O Yes No
If yes, please fill in the following information or submit a route map along with this application:
Street From To Dates Times
Page 5 of 8

===== PDF PAGE 47 =====
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SECTION 5 — PLANNING WORKSHEET AND REQUIRED TASK DUE DATES*
Use this form to determine the date each of these tasks needs to be completed. For tasks that do not apply,
please mark “N/A” in the Due Date column. If the Due Date falls on a weekend or holiday, the Due Date
becomes the next normal business day. However, this does not affect the other Due Dates, as they are only
dependent on the date of the special event.
Note: This section must be completed by event organizer prior to notary signature,
Date of Special Event:
Tasks to be completed Days Due
(All items due to City unless noted) Before Event Due Date
Submit “Intent to Meet Insurance Requirements” : : i nati
+ . ; , Prior to Prior to application
Document (included with Special Event Permit sti F :
Application, pg.2) ____| application review | _feview
Submit Special Event Permit Application 90 days
Submit Carnival Permit Application , 90 days
Submit Fireworks Permit Application 30 days
Submit Temporary Liquor License Application 30 days
| Submit Building (Temporary Tent) Permit. =~) ee |
. 30 days
Application
Submit Temporary Food Service Permit
Application(s) 30 days
(DuPage County Health Dept. — 630-682-7979)
Submit Original Certificate of Insurance* 21 days*
Submit Raffle Registration Application 14 days
Notify residents/businesses of special event 14 days
Post “No Firearms” signs at all public entrances
(See IL State Police requirements for standardized N/A Day of Event
sign in West Chicago's Special Events Policy)
“fi this requirement is not met, the proposed event may be cancelled.
Page 6 of 8

===== PDF PAGE 48 =====
[Extraction: OCR (rendered-page OCR)]
SECTION 6 - WAIVER AND HOLD HARMLESS AGREEMENT
In consideration of the_Uest Curcago Wie\s Schoul_ (name of organization) and its Members,
employees, volunteers or guests, being allow to participate in _Frewoe¥3 , (the Activity) the
undersigned hereby recognizes, acknowledges and assumes any and all risk pertaining to
LPesk Cnicase {igw Selywol (name of organization) participation in the Activity.
To the fullest extent permitted by law, the Les Oniewee Hach. Seheo | (name of organization)
hereby agrees to defend, indemnify and hold harmless the City of West Chicago, its officials, agents and
employees, against all injuries, deaths, loss, damages, claims, suits, liabilities, judgments, cost and
expenses (including attorneys fees), which may in anywise accrue against the City of West Chicago, its
Officials, agents and employees, arising in consequence of West Cs cago Wig Sclanl(name of
organization) participation in the Activity, or which may in anywise result therefore, except that arising out
of the sole legal cause of the City of West Chicago, its agents or employees. The
Wek Chi pase Wigh Schoal (name of organization) shall, at its own expense, appear, defend and
pay all charges of attomeys and all costs and other expenses arising therefore or incurred in connections
therewith, and, if any judgment shall be rendered against the City of West Chicago, its officials, agents
and employees, in any such action, the West Cuicaco Viel Soveot (name of organization) at
its own expense, satisfy and discharge the same.
The invalidity or unenforceability of any of the provisions hereof shall not affect the validity or
enforceability of the remainder of this Agreement.
The undersigned represents it has full authority to execute this Waiver and Hold Harmless Agreement on
behalf of the West Civeage Vichy Sohwo' (name of organization).
Agreed this 2% day of September , 2024
Leck Cah eon High Schoo!
Name of Organizafton
Leonel be,
tint Name of Authoriéd Person
cee mee Person
Direct of flnsinery SO-Vees
Title
Page 7 of 8

===== PDF PAGE 49 =====
[Extraction: OCR (rendered-page OCR)]
The Organization and the authorized signatory below agree to inform the City of West Chicago of any
changes in the application at least thirty (30) days prior to the event. Please note: Final approval of
this event is pending satisfactory completion of Certificate of Insurance requirements.
Signatory agrees to abide by all requirements of the Special Events Policy, including
compliance with the State of Illinois Firearm Concealed Carry Act.
*All applications must be signed and notarized.
Lest Chicago Wigh Scho —-__ ane! 0 _ as/ay
(Name of Organizatidn) (Print Name of &gnatory) (Date)
By tT
i ta lic
Expives January 19,2028 (Notary Public)
Signed and sworn to before me this 2 > day of Sea timttd » 20 24
After submitting all forms, your application will be reviewed by City staff. All departments that will be
involved in providing services or permits for the event will be notified. Please do not assume that all
aspects of the event will be approved. You may be asked to make some changes to your plan
based on the availability of services or scheduling of other events.
The City of West Chicago reserves the right to cancel any event at any time for reasons deemed
necessary by the City Council and/or City Administrator.
Deliver all completed items to:
City of West Chicago
Attn: Community Development ~— Special Events
475 Main Street
West Chicago, IL 60185
SERRE ERS EERE ERR ESHER EERE RR TEE RORY ERNE ORES ERE ERK ETRE END EERE M EER EN ERE KOU EEE REE EA ETE ROR ROR EEE R SEEDERS EbA TE hanewne
FOR OFFICE USE ONLY
Salalah dahatalilalalilalahaiadelshsiahaialelalahdehhelebtabetsleieiehelhisheh btbhitelLbbibbieicdied hitb nikita ikdaed kick cat eek GCL COE
Based on the information which has been submitted and contingent upon approval of any necessary inspections
the day of the event, the request for a permit has been:
© Approved Permit No. __ __ 0 Denied
eni
Remarks:
Authorized Signature
Title Date
Page 8 of 8

===== PDF PAGE 50 =====
[Extraction: OCR (rendered-page OCR)]
“a We DATE (MMIDDIYYYY)
ACORD CERTIFICATE OF LIABILITY INSURANCE
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
Acrisure, LLC dba Britton Gallagher & Associates
3737 Park East Dr. STE 204 a.Bxth, 216-658-7100 {N6, Noy: 216-658-7101
Beachwood OH 44122 ;_info@brittongallagher.com
INSURER{S) AFFORDING COVERAGE NAIC #
INSURER A : Everest indemnity Insurance Co. 10851
Pyreasanicd Fireworks Inc. 2288) wsuRER 8 : Everest Dena Insurance Company t 16044
P.O. Box 149 wsurer c : Arch Speciality ins Co 21199
299 Wilson Road INSURER D : Pennsylvania Insurance Company |
New Castle PA 16103 INSURER E :
INSURER F
COVERAGES CERTIFICATE NUMBER: 134465180 REVISION NUMBER:
THIS 1S 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 JAOOL/SUBRy POLICY EFF | POLICY EXP
T TYPE OF INSURANCE Jinse| wp | Pi NUMBER. Mi
A | GENERAL LIABILITY y|y roriazo23 | t0/1472024
Umits
EACH OCCURRENCE $ 1,000,000
PREMIS! ES (Ea occurance) _| $ 500.000
MED EXP (Any one parson) $
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000 :
PROOUCTS - COMP/OP AGG | $ 2,000,000
X | COMMERCIAL GENERAL LIABILITY
ciaims-mave |X | occur
GENL AGGREGATE LIMIT APPLIES PER
poucy [|X] 89 [ |roc
B 7 AUTOMOBILE LIABILITY
| tonanozs 10/14/2024 So SINGL
X | any auto BODILY INJURY (Per person) | $ -
ALL OWNED SCHEDULED 1
Bins Auios [soon INJURY in accldent)| $
X | uireoautos | X | Autos [ | (er accident) 8
s
| c umereLLauaBs | X | occur Y | tonao2s | tartanoz4 [ exch occurrence $ 4,000,000
X | excess uas CLAIMS-MADE AGGREGATE $4,000,000
ozo |__| retentions _t $
D | WORKERS COMPENSATION vorazozs | tonanoza Ix TWOSTATU.] lore
AND EMPLOYERS’ LIABILITY vi is
ANY PROPRIETORIPARTNERVEXECUTIVE E.L. EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) E.L. DISEASE - EA EMPLOYER] $ 1,000,000
if yes, describe under
DESCRIPTION OF OPERATIONS below | | [EL DISEASE - POLICY LIMIT | $ 14,000,000
toriaz023 | 1011472024 [Each Ooo Aggregato $5,000,000
Fetal Gite °° $10,000,000
_t
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES {Attach ACORD 101, Additional Remarks Schedule, If more apace Is required)
Additional Insured extension of coverage is provided by above referenced policies where required by written agreement.
Fireworks Display Date: October 18, 2024
Location: 326 Joliet St, West Chicago, IL 60185
eo Insured: West Chicago Community High School, West Chicago Fire Protection District, City of West Chicago, its Officials, Employees, Agents and
olunteers
L.
CERTIFICATE HOLDER CANCELLATION
;
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
oe ACCORDANCE WITH THE POLICY PROVISIONS.
West Gnicage Community High School
326 Joliet St. West Chicago
West Chicago IL 60185 AUTHORIZED REPRESENTATIVE
—l
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ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD