Receipt

You will be provided with a Receipt upon submission.

LYH Special Event Permit Application

Event Information

Event Name

Event Start Date

Event End Date

Event Occurrence

First Time Event

Annual Event

If this is an annual event, what is the longevity of the event? (Ex:5 years)

What is the Overall Estimated Attedence for the Event?

Event Categories (Check all that Apply)

Community Festival

Concert

Run/Walk

Parade

Bike Race/Tour

Will Alcohol be Served?

Yes

Will there be an admission or entry fee?

Yes

Admission/Entry Fee (Check all that apply)

In Advance

Day Of

Name of Event Organizer

Event/Organization Website

Employer Identification Number (Tax ID)

Are you a Non-Profit Organization?

Yes

Email Address

Work Phone Number

Cell Phone Number

Secondary Contact Email Address

Secondary Contact Phone Number

Is another individual, organization, or business sponsoring this activity?

Yes

Name of Sponsoring individual(s), organization(s), or business(es):

Description of Event (provide thorough details of event, activities, programs, and schedule):

Event Venue / Site(s) (provide thorough details):

Public Access

Time open to the public

Time closed to the public

Event Time

Actual Event Start Time:

Actual Event End Time:

Noise Information

Music/Sound Start Time:

Music/Sound End Time:

Alcohol Information

Alcohol Service Start Time:

Alcohol Service End Time:

Back-Up Event Date

Public Access

Time Open to Public:

Time Closed to Public:

Event Time

Actual Event Start Time:

Actual Event End Time:

Noise Information

Music/Sound Start Time:

Music/Sound End Time:

Alcohol Information

Alcohol Service Start Time:

Alcohol Service End Time:

Event Merchants & Vendors Information

If unnecessary please leave blank.

Food Served / Sold at Event:

Yes

How many food vendors?

Food Vendor Access

# of Vendors Needing Electricity:

# of Vendors Needing Water Access

Cooking Method (check all that apply) If Other, please specify.

Charcoal

Electric

Gas/Propane

How many retail vendors?

Retail Vendor Access

# of Vendors Needing Electricity:

# of Vendors Needing Water

# of Other Vendors:

Describe Items/Services:

Other Vendor Access

# of Vendors Needing Electricity:

# of Vendors Needing Water

Event Venue Set-Up and Break-Down Information

Event Set-Up

Event Venue Set-Up Date: *

Start Time *

End Time *

Event Break-Down

Event Venue Break-Down Date: *

Start Time *

End Time *

Additional Venue(s) or sites required for Event set-up or staging:

Requested street(s) to be closed:

Proposed date(s) and times of street closures:

Will You Be Supplying Any of the Following Items or Elements at Your Event?

If unnecessary please leave blank. If YES, please enter the amount OR description in the text box area.

Dumpsters

Yes

Portable Toilets

Yes

Trash Cans

Yes

Recycling Cans

Yes

Banners or Signs

Yes

Fencing

Yes

Barricade

Yes

Special Lighting

Yes

Shuttle Services

Yes

Site Decorations

Yes

Catered Food

Yes

Live Entertainment

Yes

Stage, Bleachers, or Other Structures

Yes

Fireworks, Fires, or Pyrotechnics

Yes

Name of Fireworks Contractor (if applicable):

Booths, Exhibits, or Displays

Yes

Tents or Canopies

Yes

Vehicles/Trailers

Yes

Animals

Yes

VIP Area

Yes

Amplified Music/Sound

Yes

Rides/Inflatables, Other Amusement Items

Yes

Event Day Staff

Yes

Quantity

Hours

How Will You Obtain Event Staff?

Are You Requesting that the City of Lynchburg Provide Any of the Following Items/Elements for Your Event?

Electrical Service

Yes

Describe

Water Service

Yes

Describe

First Aid Service provided by Lynchburg Fire Dept?

Yes

Describe

Crowd Control Barricades

Yes

Describe

Unique Grounds Preparation Needs

Yes

Describe

Stage. *(note stage is 16’ by 24’; Cost: $750.00; stage has lights and canopy but needs electric)

Yes

Other City Services

Yes

Describe

How Many Staff Persons Will You Have Working the Following Areas:

Entry/Exit Gates:

Clean Up Crew

Beer/Wine Garden Area:

Parking:

Stage

Other

How do you Plan to Notify Residents and Businesses Who May be Affected by Your Event? Please check all that apply.

Door to Door

Flyers

Phone Calls

How do you Plan to Market/Promote Your Event? Please check all that apply.

Tv Ad

Radio Ad

Newspaper

Street Banner

Website

Social Media

Billboards

Security

For events in downtown Lynchburg, the Department of Parking Management enforces parking rules Monday – Friday from 8 a.m. to 5:00 p.m. If parking is needed in a facility where paid parking is in effect during enforcement times, additional costs may apply to reserve a parking space(s). Please contact Parking Management for information on the Temporary Parking Permit Policy 434-455-4240

Do you request that the Lynchburg Police Department provide security for your event?

Yes

If yes, how many officers will you request?

Event Parking Information

Will the event be utilizing an off-street public parking facility for the purpose other than public parking?

Yes

Will the event be utilizing on-street public parking for the purpose other than public parking? (Examples include stage set-up, tents, reserved VIP parking, additional handicap spaces, vendor parking, etc…)

Yes

Please select which City supplied additional items will be needed to re-direct public parking.

Cones

Barricades

Signage

Please provide a description detailing how your event will impact parking. Include location and number of cones, barricades, and/or signage if needed.

Liability Insurance Information

A certificate of insurance for this event must be presented to the City of Lynchburg Office of Economic Development & Tourism Special Events Coordinator no later than fifteen (15) calendar days prior to the start date of the event. If the information requested below is not available when this application is submitted, it can be added later, but not later than the fifteen (15) day deadline previously noted.

Insurance Agency

Policy Number

Agent’s Name

Business Phone Number

Policy Limits

Indemnity Agreement

In consideration for the City of Lynchburg granting the undersigned Event Organizer representative permission to hold the proposed event on public property and to display, sell, or offer for sale wares, services, and/or food or merchandise within the perimeters of their event venue, the undersigned agrees to assume the defense of and indemnify and save harmless the City, it's employees, offices, and agents against any and all claims, liabilities, judgments, costs, causes of action, damages, expenses, and shall pay all attorney's fees, court costs, and other cost incurred in defending such claims, which may accrue against, be charged to, be recovered from, or sought to be removed from the City, its employees, officers, and agents by reason of or on account of any personal injury or death or damage to property arising from the undersigned's event and associated activities, if such personal injury or death or damage of property is caused by the acts or omissions or negligence of the undersigned, or the undersigned's employees and agents or by such acts, omissions, or negligence of any other person subject to the undersigned's control. The City, its employees, officers, and agents shall not have to give the undersigned any specific types of notices of such claims.

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