HomeMy WebLinkAboutKimball Senior Center Facility use ApplicationName: GeJ r7�,
Name:
-CALIFORNIA
N A
City of National City
Facility Use Application
140 E. 12111 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 ;
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Facility Requested: please circle DEC 0 V 2010
Martin Luther King Jr. Building S, 3 iCE ') Granger Music Hall ..
North Room South Room Entire Faciti TiONAi. � f%
Date(s) of Use: 3 —1 I Day(s) of Use: vV 66N S A `i
Time of Use: From: oD /PM To: /D :OD Al IPM — INCLUDE SET-UP & CLEAN UP TIME
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Type of Function/Activity: At -✓A, 5 5/U 44'AST' Is the event open to the public? MO
C'Du4iry , i ALD y'= G'1/ele-frif-/51— UQG iv/Zr71-77 0 At/
Name & Address of Organi~nation/Group:Www) ,a/�C//e /f V/ J4-N o/r.60/ C41 9 ,21 n /
Non- profit organization:
No Tax ID #
Anticipated Maximum Attendance: 9 --/D 0 Percentage of National City Residents 2 �o
Will Admission be charged? YY5 Amount $ e Will this be a Fund Raising Event? /VD
Equipment Requested: / # of chairs /1& # of banquet tables Stage
YE-5 Podium/Microphone * *PLEASE ATTACH SEATING DIAGRAM** I
Use of Kitchen: Yes / No Use of Gas for Range and Oven: Yes V No
Is the Use of Alcohol Requested? _
Will other paid services be used (I. e, commercial. caterer, DJ, Band, etc)? l/ Yes No
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CP3,‘ITTLA.
Phone: Igya,5 --.lo_3q.0
Phone:
I-Iow 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 HAVE RECEIVED A COPY OF THE RULES AND REGULATIONS 1sOR
THE FACILITY REQUESTED, AND I AGREE FOR MY ORGANIZATION/ GROUP TO
CONFORM TO ALL OF ITS PROVISION.
DATE COMPLETED: //- /a ` /0
PRINT NAME: /,'e4 C / A -T /�-5
SIGNATURE:
ADDRESS OF APPLICANT: /600,4G1 /T/c. Hwy ` gm 7--o9
CITY, STATE, AND ZIP CODE: J.4AJ b/z Q 99,/O /
PHONE: DAY 663o FAX NUMBER: 15 - z56
CONTACT PERSON ON TilE DAY OF TI`IE EVENT: 0/241 4-77c/AC5
PHONE: ( ) ...._............. .._... — CELL: ( ) .1. 1-4! -7 70
HAVE YOUR COPY OF
APPLICATION IN
POSSESION DURING USE
Please type or print clearly with a
Ballpoint pen. Complete
application must be submitted
and payment submitted in
advanced of the event.
Cormmunity Services Staff Only -
Rental Amount Received: ..._.......__._..._____._ Receipt \umamor:.,,.__..._,
Deposit Amount: Deposit/ Rev Returned:....-----_._.__._.
Check __---- Key issued: _....__. _.. YES __ NO
CITY OF NATIONAL CITY
PUBLIC PROPERTY USE HOLD HARMLESS
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,
b/ eo zi/V %y
Organization: eCV/V7Y E, /oLo S ehi /TX.5I
Person in charge of activity: //1"ite/ a/i?-77 /.,v5
Address: 4.0e) 4¢-6//--ie fr'h/y Z..A72 9,
/587-5-05--4,5g0 ram)
Telephone: ,f5t- 6#- 977o Cc) E-Mail: /z 'Cc V
City Facilities and/ or property requested: Xixie4tti eeivreR
Date(s) of use: /11,9,ee*f _23 20/l
HOLD HARMLESS AGREEMENT
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.
//- // 0
Vria 'c of applicant Date
Certificate. of Insurance Approved by
Name and Title
County of San Diego
CARLOS G. ARAUZ, iPMA-cr DEPARTMENT OF HUMAN RESOURCES (619) 578-578s
DIRECTOR 444 WEST BEECH STREET, 3RD FLOOR, SAN 1DIEGO, CALIFORNIA 92101-2.942 . FAX (619) 57B-5756
STATEMENT OF COVERAGE
It is hereby certified that the County of San Diego is self -insured for Commercial General
Liability, Commercial Auto Liability and Worker's Compensation. Claims are processed and
administered in accordance with the California Government Code and California Labor Code.
This statement is issued at the request of the person or organization named below as a
matter of information only and confers no rights upon the holder of the Statement, This
Statement does not amend, extend or alter the self -funded program of the County of
San Diego.
City of National City
Community Services Department
140 East 12th Street, Suite A
National City, CA 91950
This statement is issued as respects:
Use of facilities on March 23, 2011 by the San Diego County Employees Charitable
Organization (CECO).
This Statement is not valid unless signed by an authorized representative of the County of
San Diego.
November 12, 2010
Cassandra A. Tens
Human Resources Analyst
Risk Management Division
For information regarding above, please contact the Risk Management Division at
(619)578-5786.
Winner IPMA-HR Large Agency Award far Excellence
Winner SD SHRM Workplace Excellence Award
i
Safety/ Security
Please describe your procedures for crowd control and internal security:
GV/GL ,e36 /A(
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:
Monitoring Alcohol Consumption
Please describe your producers for monitoring alcohol consumption:
Na 4LeoyoG yv/44- BE ~.5-ExiT
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:
Fees and Costs:
SUMMARY OF CIIARGES
Service Clubs: $100/month
Other Organizations: see prices below
y(ykAtO \
.\
Martin Luther King Jr. Community Center
Activity South Room North Room Entire Hall
Dining:
0-73 $23.45/hr
0-149 $70.36/hr
150-221 $87.95/hr
222-294
Dance!
Assembly:
0-100 $23,45/hr
101-157 $29,32/hr
158-300 $70.36/hr
301-472 $87.95/hr
473-630
$117.26/hr
$117.26/hr
Casa de Salud, El Toyon Recreation, Camacho Recreation & Kimball Recreation Center
$23.45/hr
*Please note Camacho Gym falls under 801 Policy Fee
Kimball Senior Center
0-149 $70.36/hr--�
151-221 $87.97/hr
Kitchen: $10.00/1n•
$50.00 Minimum — (only to be used in conjunction with the use of the hall)
$60.00 Kitchen Deposit — (required, can not be waived, and refundable upon approval from
Public Works staff)
$22.00/hr. during working hours and $35.00/hr. for overtime hours
hrs Total$ 2 ei • 474
Custodial charge shall be charges for set up, clean up and duration of event based on the
events' estimated attendance as follows:
1-100 person lhr. set up and lhr. clean up
101-157 2hr. set up and 2hr. clean up
158-300 3hr. set up and 3hr. clean up
301-472 4hr. set up and 4hr. clean up
473-630 5hr. set up and 5hr. cleanup
**PLEASE NOTE: ADDITIONAL CHARGE FOR TABLES AND CHAIRS $1.00
PER TABLE, $.75 PER CHAIR**
County of San Diego
CAI LOS G. ARAuz, 1PMn-OP DEPARTMENT OF HUMAN RESOURCES 0514j578.5706
DIRECTOR 444 WEST BEECH STREET, e° FLOOR, SAN DIEGO, CALIFORNIA 92101-2942 FAX (610) 578-5756
STATEMENT OF COVERAGE
It is hereby certified that the County of San Diego is self -insured for Commercial General
Liability, Commercial Auto Liability and Worker's Compensation. Claims are processed and
administered in accordance with the California Government Code and California Labor Code.
This statement is issued at the request of the person or organization named below as a
matter of information only and centers no rights upon the holder of the Statement. This
Statement does not amend, extend or alter the self -funded program of the County of
San Diego.
City of National City
Community Services Department
140 East 12' Street, Suite A
National City, CA 91950
This statement is issued as respects:
Use of facilities on March 23, 2011 by the San Diego County Employees Charitable
Organization (CECO),
This Statement is not valid unless signed by an authorized representative of the County of
San Diego.
November 12, 2010
Cassandra A. Tena
Human Resources Analyst
Risk Management Division
For information regarding above, please contact the Risk Management Division at
(619)573-5786.
Winner IRMA-NA Large Agency Award for Excellence
Winner SD SHAM Workplace Excellence Award
DEC-0?-2010 13:43
COSD GENERAL SERVICES
I y •
/L.1 4-2.C/4 Ez_LF,A1/1
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TOTAL_ P. 03
FUP FEE WORKSHEET
RECS, KSC/CASA, NUTRITION) I
EventlGroup Name: CECO Awards Banquet (Co. Employee Charitable Org.
Date(s) Rqsfi'd: Wed 3/23/2011
Time of Event: 6am-10am
Frequency: One Time: XXX
Council Date: n/a
RENTAL RATES
# Hours:
ShortTerm:
Hourly Rates
4
# People:,
On -Going:
CountySD
100
MLK (for dining) People South North Entire Qty,
MLK (dance/assembly)
Rec. Centers & Casa
0-73
73-149
150-221
222-294
$23.45 n/a n/a
n/a
n/a
n/a
0-100 $23.45
101-157 $29,32
158-300 n/a
301-472 n/a
472-630 n/a
varies
Kimball Senior Center 0-149
150-221
Service Clubs Only $100.00
KITCHEN ($50 min) $10.00
FAC/BLDG USE FEE $50.00
CUSTODIAL (Dep/PW)_.
Duration $22/hr reg, or $35/hr OT
Setup/Cleanup time $22/hr reg, or $35/hr OT
$70.36 n/a
$87.97 n/a
n/a $117.26
n/a
n/a
$70.36
$87.95
n/a
per month
per hour
1-100(2hr), 101-157(4hr), 158-300(6hr), 301-472(8hr),
CSD STAFF(Dep/CSD) $11,00 per hour
EQUIP: chairs: $0.75 each
tables: $1.00 each
TOTAL FEES
DEPOSITS
Kitchen: $60,00
Cleaning 1 $100.00
Key Deposit $100.00
Total Deposits:
. .
Refundable
Refundable
Refundable
n/a
n/a
n/a
n/a
$117.26
$23.45
$70.36
$87.97
Months:
Hours:
Rate
$22.00
$22.00
478-630(10hr)
Hours:
Qty:
Qty:
Fees/Council Date reVewedieonfirmed with:
k-Y--) 171 eml \o/
Applicant submitted check for $281.44 with application. This covers room rental only. W is already there in the
4
Total
Charge
$0,00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$281.44
$0.00
$0.00
$0.00
$0.00
Notes
Value of check they
submitted
waived
$0.00 waived
$44.00
$0.00
128 $96.00
16 ,$16.00
1
$0.00
$100.00
$0.00
$100.00
ACCOUNTING: $393.44 00'1-41000-3572
$44.00
$0.00
Notes:
21( VIA Ci
Date:
626-422-223-102
001-441-000-100
'OW
morning to let them in so I waived fee. Chairs are not normally set up on Wed, so PW would have to set up/tear down.