Permit Application Public Building Use INSTRUCTIONS 1. Complete application in its entirety. Please include all applicable attachments. Please type or print. 2. Submit to the County Administrator, 667 Ware Rd., Woodstock, IL. 60098, mailing address, 2200 N. Seminary Ave., Room B120, Woodstock, IL 60098. 3. Permit will be issued to the applicant within ten (10) business days of receipt of this application. 4. In submitting a permit application, the applicant acknowledges that he/she understands, and is subject to, the McHenry County Building Use Ordinance. I. APPLICANT INFORMATION ORGANIZATION REPRESENTED (If Applicable) Full Name: Street Address: City/State/Zip: Telephone Number: |
II. DESCRIPTION OF PROPOSED USE Proposed Use: Proposed Date (s): Proposed Hours: (NO MEETING BEYOND 10:00 P.M.) Proposed Location (s): Estimated Number of Persons Attending: Name and Address of Responsible On-Site Attendant (s): III. Applicant assures that applicant organization is tax exempt or has applied to the IRS for a determination of tax-exempt status under 26 U.S.C. 501 (c)(3), (c)(4), or (c)(5), and the IRS has not yet issued a final administrative ruling or determination of this status. IV. Applicant assures that individuals engaged in the authorized solicitation of funds shall visibly wear identification at all times while on County controlled property containing the individuals name, address, telephone number, and name of applicant organization. V. The applicant shall indemnify, hold harmless and defend the County of McHenry, its officers and employees against any and all liability, loss, costs, damages, expenses, claim or actions, including attorney’s fees which the County of McHenry, its officers or employees may hereafter sustain, incur or be required to pay, resulting from the negligent, willful or wanton acts or omissions of the organization, its employees and agents, without limitation, arising out of or resulting from the use of the County of McHenry’s facilities. limitation, arising out of or resulting from the use of the County of McHenry’s facilities. |
VI. If the applicant (or the applicant organization) is insured, a certificate of insurance detailing the type and amount of coverage (per occurrence and in aggregate) shall be submitted to the County Administrator’s Office at least ten (10) business days prior to the intended use date. Insurance will not be considered grounds for denial of a permit Signature of Applicant_______________________________________________ PERMIT NO: PERMIT FOR PUBLIC BUILDING USE This permit, as evidenced below by the signature of the County Administrator or designee, is issued in accordance with the McHenry County Building Use Ordinance and is based upon the proper application and assurances of the person named above. Approved by: Title: Date: cc: Permit File Security-Government Center or Risk Management Facilities Management |
(Ord. O-201112-12-049, App. 2, passed 12-6-2011)