HomeMy WebLinkAboutFacility use applicationGALipoittn4
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The 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.
Facility Requested: please circle
Martin Luther King Jr. Buildia
North Room South Room Entire Facility
-ED
,OfviiMuNffY SERVICES DER
AT AL Girt, oh
Date(s)of Use: 44/NjI1Dy(s)
f 't )1 �`'of Use: �l %S�i�i
SA2, /PO s?'l--1
Time of Use: From: Sf j u AMIPM To:
AM/PM — INCLUDE SET-UP & CLEAN UP TIME
Type of Function/Activity: Uk A I-i--0-0)1 Ttv-Pil—ls the event open to the public? 7 ` >
Name & Address of Organization/Group: {P J DE- `ds'N 71)l -(s\c3 1 2-cis e o tD`zL. v.40 5\Kik
;lk 11_ _ L g giNiQ oct, k.; CI) 1 L1.0
Non- profit organizatioi . es 7 No Tax II) # 3 ?-. O g 2 -k c) W C)
Anticipated Maximum Attendance:
Will Admission be charged? LI Amount $
Percentage of National City Residents 0 96
Will this be a Fund Raising Event? p
INC Equipment Requested: # of chairs ## of banquet tables i\IA) Stage
Podium/Microphone
Use of Kitchen: v/ Yes No
Is the Use of Alcohol Requested?
Will other paid services be used (I. c, commercial caterer, 1:).1, Band, etc)? Yes V No
**PLEASE ATTACH SEATING DIAGRAM**
Use of Gas for Range and Oven:
Name: Phone:
Name:
{ L i'.1./
'�1 1
Lk
('
Phone:
Yes iV No
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'1\*1')°\NNO*4.0AS
DATE COMPLETED:
How many times in the last twelve months have you requested to use a City Facility?
It: is expressly understood and agreed tliat 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 ally 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 IIAVE 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.
/-7I�1
PRINT NAME: P C \ 4Jb
SIGNATURE:
ADDRESS OF APPLICANT: 29 } id\ f t iv'6 ) bt\O-
CITY, STATE, AND ZIP CODE: c� 1i CIS+ � 710
PHONE: DAY . i_ Oil AX NUMBER: 4i2J . Jo7 .s 6' 6
CONTACT PERSON ON TI"IE DAY OF THE EV1Nr: { A �l
PHONE: t CE1..I.41/.... 1 1106
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.
J\-yAAEo
C..L • (11 /241
Rental Amount Received
Deposit Amount:
..................
Chrc3:
Community ui ity Services Staff Only -
Receipt Number
Deposit/ Key Rettn-nct3.
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 g 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: 1-4 *S- D `L_SPri
Person in charge of activity: t r rp v Y D
Address: 21 t— kiVt vL -D Zg
Telephone: to 1� �''1 1 () d E-Mail: "v4L-- S D( )1(k014-42 S �' •• J
City Facilities and/ or property requested: k- ,1.- (CuJlT( Cc k -t - C_
Date(s) of use: III3. Chcfhi
)MOLD 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.
Signature of applic nt
Date
F
i'Gl d � Certificate of Insurance Approved by �s- ___._...._._._...�...._,.__._-
1-J1d14
Nanand Till
Safety/ Security
Please describe your procedures for crowd control and internal security:
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:
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 1-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:
AUI: cittN[A
•
Community Services Department
140 East 12th Street, Suite 13, National City, CA 91950
(619) 336-4290 Fax (619) 336-4292
www.nationaleityca.gov
Applicant Information
(Please be sure to print in blue or black ink)
C )"1'oday's Date: / / i
Name: SO •12\- 15(k UA L
Address:
Organization: 11 P" bE,5i'1
iJ ' �. 1uo -. z z.8,
City/ State/ Zip: �� _�? Gr Z(
Phone: tU 1 7.° Contact' 1 Pr 4\-1'C1 i 0
Field / Facility / Park Requested
Please check all that apply:
El Toyon Park _ Kimball Park : Las Palmas Park
Sweetwater Heights Park Camacho Gym Pool
Tel Toyon Rec. Ctr._ ra. cho Rec. Ctr__
Casa De Salud___- (iznball.Senior Centre Nutrition Center
Activity
Please circle appropriate activity:
Astrojurnp Meeting Rooms) Athletic Field rental': 13aseball* Football*
Softball* o ey)all* Basketball' Tennis Soccer* Picnic
Swimming Other ..-_.-......-.._._
*If reserved for league play, you must submit: a team roster with addresses'within 10 working days.
Amount: Date Paid: / l _ lnit.ials:
Field / .i+acility Information
Dates requested: / 11 /20 1 I to / i` /20 11
Days of the Week and hours requested
lls Monday Tuesday ...ednesday
F rozn:
To
'.rota1
ID-- number of participants at your event
'IN*"auka
Revised 11 / 2010 ei; 50-W 5o W t-`S'N 14.=U4444> q$A Yv1/40.1-s1,4
C ,%-Q0
Thursday
Friday
Saturday
of participants National City residents
Sunday.
lU
�'rvc(iti i�tair stiT=
Community Services Department
140 Bast 12d' Street, Suite 13, National City, CA 91950
(619) 336-4290 Fax (619) 336-4292
www. nationaicityc goy
Field / Facility Request .Form Checklist
Requesting Organization: ke *d -
Name: U Date: /
Please initial all sections of this checklist:
Hold Harmless / Indemnification
Current Organization's Bylaws
____Current Audited Financial Statement Preliminary Roster Data
Received Copy of City Council Policy 801
Field / Facility Request Fann
Current hnsurance Certificate
Current Roster Data
(By 2" d Game of Season)
Public Property Use Mold Harmless and Indemnification Agreements
Person's requesting use of City property, facilities or personal are required to provide a minimum of $1,000,000
Combined single limit insurance for bodily injury and property damage which include the city, it's officials, agents
And employees named as additional insured and to sign the I -fold Harmless Agreement, Certificate of Insurance must be attached
to this Permit.
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 ail 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 cost of litigation, arising out of or related to the use of
public property or to the activity taken under the permit by the perrnitee or its agents, employees or contractors.
lave read and completed the above form to the best of my knowledge
,�
Signature: :a`-� Date:
Community Service Department S f Use Only
Verified By: e, Date:_ -I_ / / �.� .....
PRINT NAME
Signature:
FOR DEPARTMENT USE ONLY
PARK. DIVISION APPROVAL..: 'YES NO DATE: I 1
COMMUNITY SERVICES APPROVAL: YES
NO DATE: / /
NOTE; ALCOHOLIC DEVERAGES±SIVIOKING BANNED.) IN
ALL FIELDS / FACILITIES/ PARK
I.cvvise I 1 1/20I0
ll
r
�nrcon',on4Ti i)
Community Services Department.
140 East 12th Street, Suite B, National City, CA 91950
(619) 336-4290 Fax (619) 336-4292
www.nationaleitycgov
Applicant Information
(Please be sure to print in blue or black ink)
Today's Date: / �% /
Name: GvtY I A -/;1 Organization:
I Alf) Oft t, St a 1� Z ?
Address: z `} � � � �
City/ State/ Zip: CJ _. '�J 1 . {1` ( (-1 2. [t.D`\
Phone: U 7 1 '7 - U� Lontact: ( ./CS-Pc'L:\ PcOL=
Field / Facility / Park Requested
Please check all that apply:
El Toyon Park Kimball Park Las Palmas Park
Sweetwater Heights Park Ca nacho Gym Pool
El Toyon Rec, Ctr. I imball Rec.Ctr.2_ Camacho Rec. Ctr
Casa De Salud Kimball Senior Centre Nutrition Center
Activity
Please circle appropriate activity:
Astrojump Meeting Room Athletic Field rental* Baseball* Football*
Softball* Volleyball* Basketball* `.Tennis* Soccer* Picnic
Swimming Other
*If reserved for league play, you mist submit a team roster with addresses within 10 working days.
Amount: Date Paid: / / Initials:
Field / Facility information
Dates requested: / /c/ /20 /j to _I_ l Y /20 it
Days of the Week and Hours requested ._
Days Monday Tuesday Wednesday
.1row:
To
'rota]
Thursday
Fri clay -1 Saturday
p11
number of participants at your event 9. .., of partieipanis National City residents
v. r‘l .i- is d,111/120I0
. 1,,.--,
t
U1
Stiiaday
*--TDQZ44 9. ID
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m
Community Services Department
140 East 121' Street, Suite B, National City, CA 91950
(619) 336-4290 Fax (619) 336-4292
www.nationalcitvca,gov
Field / Facility Request Form Checklist
Requesting Organization: /4 A tit cSM U+ 3
� Name: So A S � � Date: � / 7 1 r✓
Please initial all sections of this checklist:
Field / Facility Request Forin
Current Insurance Certificate
Current Audited Financial Statement
Current Raster Data
(By 2"a Game of Season)
mmllold Harmless / Indemnification
Current Organization's Bylaws
Preliminary Roster Data
Received Copy of City Council Policy 801
Public Property Use hold Harmless and Indemnification Agreements
Person's requesting use of City property, facilities or personal are required to provide a minimum of $ 1,000,000
Combined single limit insurance for bodily injury and property damage which include the city, it's officials, agents
Ancl employees named as additional insured and to sign the Hold Harmless Agreement, Certificate of Insurance must be attached
to this Permit.
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 anti hold harmless the City Of National City and its officers, employees and agents from
and against any arul 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 cost of litigation, arising out of or related to the use of
public property or to the activity taken under- the permit by the pennitee or its agents, employees or contractors.
1 have read and
Signature:�
omplet:ed the above form to the best of my knowledge
Community Service Department Stair Use Only
Verified B yr4reeiNda,
PRINT NAME
Signature:
Date: I 1 � � /
Date: _..... / r /
FOR DEPARTMENT USE ONLY
PARK DIVISION APPROVAL,: YES NO DATE: 1 I
C0IV.111\'11:JN:1:':1'Y SERVICES APPROVAL: YES NO DATE- 1
NO' 'E; ALCM-IO LA C BEVERAGES / SMOKING BANNED IN
ALL I+1IE:I_,.US / F1A..C1.11 . DIES/ PARK.
Reviser i l/20I0
l5