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HomeMy WebLinkAboutFacility use Application American Cancer SocietyCALIFORNIA NATIONAL t 1�'�'U�tP6lixTfss The City ofA Tatiional City Fa ciAtAyng,ticyAppiliCt-- ii 1 KL 140 E. 12th Street, Ste. B National City, CA 91950 (619) 336-4290 Fax (619) 336-4292 After hours dispatch: (619) 336-4411 TO ALL APPLICANTS: It is strongly recommended that an applicant requesting use of City Facility attend the City Council meeting when the item is scheduled for consideration in order to answer any questions from the City Council. Facility Requested: please circle Martin Luther King Jr. Building North Room South Rao.1 Entire Facility Date(s) of Use: Of— bay(s) of Use: G RCS ant k-k 1'' J Time of Use: From: L m AM/PM To: 1 AM/€M - INCLUDE SET-UP & CLEAN UP TIME Type of Function/Activity: CNN. • c= • Is the event open to the public? • ye S Name & Address of Organization/Group: Rrrrn iCN-bi 1-Ls am, F No Tax ID # q `-J -117 ©3 O Percentage of National City Residents boo 0 Non- profit organization Anticipated Maximum Attendance: Z.O. Will Admission be charged? D Amount $ Equipment .Requested: # of chairs Podium/Microphone Use of Kitchen: Yes No Is the Use of Alcohol Requested? ti Will other paid services be used (1. e, commercial caterer, DJ, Band, etc)? Natne: £C.P rw ekt,f Name: Will this be a Fund Raising Event? 1J 0 # of banquet tables 9 Stage **PLEASE ATTACH SEATING DIAGRAM** Use of Gas for Range and Oven: Yes X. No Yes Phone: 6I q - (. Z-7g23 Phone: %WnWater cecLc No 2 DATE COMPLETED: PRINT NAME: (: i/ to tt SIGNATORY::: URF: i 143,416 ADDRESS OF APPLICANT: !V CITY, STATE, AND ZIT' CODE: abfr6 Ltt, t PIIONE: DAY c,'j °",l". FAX NUMBER: CONTACT PERSON ON THE DAY OF THE EVENT: PHONE: ( ) CELL: ( )---..-.. J-].ow many times in the last twelve months have you requested to use a City Facility? It is expressly understood and agreed that the applicant assumes all risk for loss, damage, Liability, injury, cost or expense that may arise during or be caused in any way by such use or occupancy of the facilities of the City of National City and/or Community Services Department. The applicant further agrees that in considerations of being permitted the use of the facilities agreed to, they will save and hold harmless the said City of National City, its officers, agents, employees and volunteers from any loss, claims, and liability damages, and/or injuries to persons and property that in any way may be caused by applicant's use or occupancy. I, the undersigned, hereby certify to abide by the regulations governing said facility and agree to abide by all City of National City ordinances and facility rules and policies, and be representative of the user organizations. Further, I agree to be personally responsible for any damage/loss sustained by the ground, building, furniture or equipment or unusual clean up occurring through the occupancy of said facilities. Application recognizes and understands that use of the City's facility may create a possessory interest subject to property taxation and that applicant may be subject to the payment of property taxes levied on such interest. Applicant further agrees to pay any and all property taxes, if any assessed during the use of the City's facility pursuant to sections 107 and 107.6 of the revenue and taxation code against applicant's possessory interest in the City's facility. I CERTIFY THAT I %IAVI's RECEIVED A COPY OF THE RULES AND REGULATIONS FOR THE FACILITY REQUESTED, AND I AGREE FOR MY ORGANIZATION/ GROUP TO CONFORM TO ALL OF ITS PROVISION. HAVE YOUR COPY OF APPLICATION IN POSSESION DURING USE _.$'=ti 1 Please type or print clearly with a Ballpoint pen. Complete application must be submitted and payment submitted in advanced of the event. Community Services Staff Only • Reen I Arnoue Received: Receipt Number: r)cposil Amount: t)chosiil Key Revelled: Check Key issttea: Yt::S NO CITY OF NATIONAL CITY PUBLIC; PROPERTY USE HOLD HARMLESS SS AND INDEMNIFICATION AGREEMENT Person requesting use of City property, facilities or personnel are required to provide a minimum of .$1,000,000 combined single limit insurance for bodily injury and property damage which include the city, its officials, agents and employees named as additional insured and to sign the hold harmless agreement. Certificate of Insurance must be attached to this permit. Organization: i \A -A c .` fi"4f'.. f;fi.. ' t..r /ti. f rN-i F ti'- l-at iJ: + 1 0C-- Person in charge of activity: Address: th � 1baES l''�: � e�_3tyv;'...L�...�j�gb, t:. rr E-Mail: C�csC:rv,.g.�s tC, Cr.'? City Facilities and/ or property requested: , o"t -.. -Rv ; : KA L-- t .- € . Date(s) of use: a L Telephone: 71 t_� HOLD HARMLESS AGREEMENT 61,2.. (e As a condition of the issuance of a temporary use permit to conduct its activities On public or private property, the undersigned hereby agree(s) to defend, indemnify and hold harmless the City of National City and its officers, employees and agents from and against any and all claims, demands, costs, losses, liability or damages for any personal injury, death, or property damage, or both, or any litigation and other liability, including attorneys fees and the costs of litigation, arising out or related to the use of public property or the activity taken under the permit by the permit or its agents, employees or contractors. 12 - Signature of applicant Date Certificate of insurance .Approved by Name and Title 4 Safety/ Security Please describe your procedures for crowd control and internal security: F_.:. ik.3 OAE' rE { Yc-/1f' €t.i[..,E f C „,.i t: .v}s k �� �1:- Vir;%avy �J S:fi._ Cr..'.i ti. ac.. C,,`'c, 2-6,i: .sLS ftt,! 11 r' Pi' k_-:fk" i'',%t;N: -u✓i l:. _...-1,t.''4 v\j'rj(5 f YES NO Have you hired any Professional Security organization to handle Security arrangements for this event? if YES, please list: Security Organization: Security Organization Address: Security Director (Name): Phone: 5 Monitoring Alcohol Consumption Please describe your producers for monitoring alcohol consumption: Organization must designate a person to ensure that alcohol is being served to persons 21 years of age or older. The designated alcohol server must also be 21 years of age or older. Name: Contact phone number the day of event: YES NO Have you hired any Professional Security organization to handle Security arrangements for this event? If YES, please list: Security Organization: Security Organization Address: Security Director (Name): Phone: 6 ACC)RD CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDINYYYY) 12/9/2010 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 INSURED American Cancer Society, California Division, Inc. PO Box 2061 Oakland, CA 94604 CONTACT NAME: PHONE ..EALC....No. Ex :._.._..._.._......__.._._.....-... E-MAIL ADDRESS PRODUCER 139199 C?ATOE!iER1P,#,_........._-........_._....._ ..... FAX _tAiC, No]: -_-.�._...._.....INSURERISj. AFFORDING COVERAGE .....,_.__.....,.__...................__...__.NAICft INSURER A: Federal Insurance Company 20281 INSURER a : Pacific Indemnity Company 20346 INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 2106146 REVISION NUMBER: See below THIS IS 70 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. ILTR TYPE OF INSURANCE 3NSR WDDL VDR POLICY NUMBER (MMIPOLDDIYCY YYYI (FF MMIDDTYYYYy LIMITS A GENERAL X _GENT X LIABILITY CLIABILITY _COMMERCIAL GENE'RAI. CLAIMS -MADE LX OCCUR AGGREGATE LIMIT APPLIES PER: POLICY 1 I JPRO-FCT i LOC 35943463 09/01/10 09/01/11 EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED PREMISES (Ea arrurrenr-e) S 300.000 MED EXP (Any one person) 5 2.500 PERSONAL & ADV INJURY S 1.000.000 GENERAL AGGREGATE S 25.000.000 PRODUCTS - COMP/OP AGG 5 2,000,000 S A AUTOMOBILE -- X --- X X LIABILITY ANYAuro ALL OWNED AUTOS SCHEDULEDAUTOS E-HIRED AUTOS NON -OWNED AUTOS 73563471 73563476-Puerto Rico 73563477-Hawaii 09/01/2010 09/01/2011 COMBINED SINGLE LIMIT (Ea accident) $ 3,000.000 BODILY INJURY (Per person) --..--.--.----.----.-.-------- BODILY INJURY (Per accident) S --_._.._ 5 .-__.................._ S S S ................_............_.........__.._........_.._...... PROPERTY DAMAGE (Per accident) UMBRELLA LIAR EXCESS LIAR DEDUCTIBLE RETENTION S OCCUR CLAIMS -MADE EACH OCCURRENCE AGGREGATE S 5 S S B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) It yes, describe Linder DESCRIPTION OF OPERATIONS Y 1 N N! A 71741355 9/1/2010 0 9/1/2011 1 I WC STATU- OTFI- .-. X LTD-RY_ LIMi7S .-. fi-..-_-.._-..._.. E.L. EACH ACCIDENT _..___...._._.._.-...-.._-_._..._-..._...__.--_-.- E.L. DISEASE - EA EMPLOYEE .............__....-___.............__....__._. E.L. DISEASE - POLICY LIMIT -.__._ ......__._.__ $ 1.000.000 ........................... ._.......___-...-__. S 1,000,000 _......................_....__-._ S 1,000,000 N below DESCRIPTION OF OPERATIONS 1 LOCATIONS f VEHICLES (Attach ACORD 101, Additional Rernarks Schedule, if more spaces required) City of National City, its officials, agents and employees are included as Additional Insured, but only with respect o liability arising from the negligence of American Cancer Society, California Division, Inc. during Relay Committee Meetings being held monthly from January, 2011 . August 2011 at Martin Luther King Jr. Community Center, 140 E. 12th Street, National City, CA 91950. CERTIFICATE HOLDER CANCELLATION City of National City 140 E. 12th Street National City, CA 91950 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 g(ry r4;n4_ ACORD 25 (2009/09) O 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACaRD CERTIFICATE OF LIABILITY INSURANCE ‘5,..r-- DATE(MMIDDIYYYY) 12/9/2010 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: PHONE I FAX INC,.No, Eat;(AIC, No): E.MAIL ADDRESS: PRODUCER 139199 CUSTOMER ID.li: INSURER(S) AFFORDING COVERAGE NATC d INSURED American Cancer Society, California Division, Inc. PO Box 2061 Oakland, CA 94604 INSURER A : Federal Insurance Company 20281 INSURER s : Pacific Indemnity Company 20346 INSURER C : INSURER D : INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: 2106155 REVISION NUMBER See below TI-IS 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 WTH 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 Anal_ 1NSR SUER WVD POLICY NUMBER POLICY EFF (MMIDDF YYY) POLICY EXP i (MMIDDIYYYY) LIMITS A GENERAL X --_--_ GEN'L ---- X l LIABILITY COMMERCIAL GENERAL ._---I CLAIMS -MADE LIABILkTY X OCCUR 35943463 09/01/10 09/01/11 EACH OCCURRENCE S 1.000.000 DAMAGE TO RENTED PREMISES (Ea occurrence) S 300.000 MED EXP (Any one person) S 2.500 PERSONAL & ADV INJURY 5 1,000,000 GENERAL AGGREGATE S 25.000,600 AGGREGATE LIMIT APPLIES PER: POLICY I 1 JECTPRO-LOC PRODUCTS - COMP/OP AGG ------------'-- 5 $ 2,000,090 A AUTOMOBILE - X LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULEDAUTOS HIRED AUTOS NON -OWNED AUTOS 73563471 73563476-Puerto Rico 73563477-Hawaii 09/01/2010 09/01/2011 COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) $ $ 1,000,004 — -- -- X X -- BODILY INJURY (Per accident) -��- S S---..--_._--_ S S --------...-------. PROPERTY DAMAGE {Per accident) -- ` UMBRELLA LIAB EXCESS LIAR DEDUCTIBLE RETENTION S i OCCUR CLAIMS -MADE EACH OCCURRENCE AGGREGATE S 5 5 S B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? N (Mandatory in NH) If yes, descrihe under DESCRIPTION OF OPERATIONS below N 1 A r 71741355 9/1/2010 9/1/2011 X 7WC QKY TA�SU- I TH- - - - E.L. EACH ACCIDENTS ........._......,..._....-...,.._.. E.L. DISEASE - EA EMPLOYEE -_..._._......._..,......-_,_,_-.,_._._..._.. _ --- E.L. DISEASE - POLICY LIMIT 1,000,000 --._......_. S 1,000,000 S -.._........ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Certificate holder is included as Additional Insured, but only with respect to liability aris ng from the negligence of American Cancer Society, California Division, Inc. during Relay For Life on June 10 - 12, 2011 at Mar Vista High School, 505 Elm Avenue, Imperial Beach, CA 91932. CERTIFICATE HO DER CANCELLATION Sweetwater Union High School District 1130 Fifth Avenue Chula Vista, CA 91911 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 ACORD 25 (2009/09) © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD