HomeMy WebLinkAboutEvangelica Facility use ApplicationName:
CACIFORHJA'-.
tigOONAttity
INcattroAAM)
The City of National City
Facility Use Application
140 E. 12m 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
South Room
RECEIVED
FEB 2
;OMMUNITY SERVICES DEP
NATIONAL. CITY, CA
Date(s) of Use: 0f Day(s) of Use: 5 cdi rd i
r
Time of Use: From:AM/To: _ q ; OD AM M INCLUDE SET-UP & CLEAN UP TIME
Type of Function/Activity: aloW CD neat
Narne & Address of Organization/Group:
Non- profit organization.
Anticipated Maximum Attendance: CWO
Is the event open to the public? ''/ ? 5
9
. _. Br� mieitcq scan _Pc,bio f A tZ -
JoAl-
No Tax ID #
Percentage of National City Residents I 8
Will Admission be charged? f4 6 Amount $ Will this be a Fund Raising Event? NO
Equipment Requested: '# of chairs # of banquet tables Stage
0 Podium/Microphone
Use of Kitchen: Yes _ No
Is the Use of Alcohol Requested? ND
Will other paid services be used (I, e, commercial caterer, DJ, Band, etc)?
Phone: )
Name: Phone:
**PLEASE ATTACH SEATING DIAGRAM**
t lse of Gas for Range and Oven:
Yes No
Yes No
NvkA - ..- \w►., trsc• -o.,0o.,A,L.0„
2
How many times in the last twelve months have you requested to use a City Facility? 6 _
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 Departtnent.
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 properly that in any way may be caused by applicant's use or occupancy.
1, 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 darnage/loss
sustained by the ground, building, furniture or equipment or unusual clean up occurring through
the occupancy of said facilities.
Application recognizes and understands Mai use of the City's facility may create a possessory interest subject to
property taxation and that applicant may h subject to the payment of property taxes levied on such interest. Applicant
further agrees to pay any and ail property taxes, i i 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 TIIE RULES AND REGULATIONS FOR THE
FACILITY REQUESTED, ANI) I AGREE FOR MY ORGANIZATION/ GROUP TO CONFORM TO ALL
OF ITS PROVISION.
DATE COMPIIF.1T n: ..
PRINT NAME: ._. r(? 1 ez,.,
SIGNATURE:
ADDRESS' OF Alj17 ;ANT: aS-( CJ • Pi%24
CITY, STATE, AND ZIP CODE: iddinnaf C t _...a_ ' t
PHONE: DAY G FA NIJ5101 l.: :24--(A6
CONTACT PERSON ON THE DAY Of 1HE I VENT: . ) .0 1 ,..
PHONE; (tom)
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.
Rental Amount Received:
Deposit Amount:
Check
n: nimity Services Staff Only-
Reco3p; ,ti°u3nhrr
I)epnsr!Key itcturned,
Kcv IssLIcd YPS NO
3
CITY OF NATIONAL CITY
PUBLIC PROPERTY USE HOLD HARMLESS
AN 1) 1 N 1) l? M N 11<ICATION AGREEMENT
Person requesting use of City property, facilities or personnel are required to provide a rninirnurn
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{ IPtIO
Person in charge of activity:
Address:
yl..
Telephone: _.....-..-(P1
k
1: Mail: It C J �a-ria al/tee)
City Facilities and/ or property requested:
Date(s) of use: 1/ J j t
[WILL-VY /C-CW Ade
HOLD 1 IA1tM1,ESS 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 ifs officers, employees and agents from and against any
and all claims, demands, costs, fosses, 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 permiytor its agents, employees or contractors.
S'gnature of applicant
Certificate of Insurance Approved by
4/P0 /./
Date
Name and Title
c it t. CCU Yri{' ' 0
4
Safety/ Security
Please describe your procedures For r crowd control and internal security:
}�? ka - c,t +_. °V e Tkm
0 i. �. S l t,
YES NO I-Iave you hired any Professional Security organization to handle
Security arrangernenr5 for this event? If YES, please list:
a
Security Ort rnii.:itic ir:
Security Orgtrnir.ation Address:
i r
Security Director (Nanic): ? � g Phone:
5
Monitoring Alcohol Consumption
Please describe your producers or monitoring alcohol consumption:
ivo 1\11 sfyvva-
Name:
Contact phone number the day of even!:
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 he 2l years of age or older.
J
YES
NO Have von hired any Professional Security organization to handle
Security arrangements tur this event? if YES, please list:
Security ()rs;anizatian:
Security Or't,arair..ation nddress:--___._..__._-__._._� _�.. ......._...___._._
Security Director (Name):
6