HomeMy WebLinkAboutFacility Use Application and insurance document=619 409 7688
02:18:54 p.m. 08-02-2011
219
i
Name:
Name:
eiceR ra€t
A'JG -2 P 2: 3 t
S fir."`.National
,i,Ct4yot City
Facility Use Application
Rev.6/28/I i
2100 Hoover Avenue
National City, CA 91950
(619)336-4580
Fax (619)336-4594
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
M 'n-Luther King Jr. Building
orth Room South Room Entire Facility
Date(s) of Use: Se ember I g/ a D (I _ Day(s) of Use:
t Crursda y
Time of Use: From: $ A!yi M To: 2- AM 4 INCLUDE SET-UP & CLEAN UP TIME
Type of Function/Activity: Plklie in -a-i iaf -tote 111 1 Is the event open to the public?
Organization/Group:
Name & Address of Or n/" piatiortal C. 4 GSM twee
a
hong/ Cj ja
r�rwnw err
states ra4crVasi¢of 33sfi leer -meat. CAA k
Non- profit organization: Yes No ax ID #
Anticipated Maximum Attendance: glut/ n.6D Percentage of National City Residents 50 %'
Will Admission be charged?� PIO Amount $ «/4 Will this be a Fund Raising Event? N d
Equipment Requested: kc>t-n chairs �3 # of banquet tables .... Stage
a f 2 Podium/Microphone
`*PLEASE ATTACH SEATING DIAGRAM]
9..fatie Cables Audio & Visual Equipment Required? (Please Specify)
Use of Kitchen: Yes /< No,� Use of Gas for Range and Oven:
Is the Use of Alcohol Requested? N
Will other paid services be used (I. e, commercial caterer, DJ, Band, etc)? Yes
t-4 ` Phone:
Phone:
Yes
X
es
No
i
®619 409 7688
02:19:18 p.m. 08-02-2011 3/9
How many times in the last twelve months have you requested to use a City Facility? 0
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 sueh 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 a11 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 iaaati06 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 tastes, if any assessed during the use of the City's
facility pursuant to sections 107 and I07.6 of the revenue and taxation code against applicant's possessory
interest in the City's &cility:
I CERTIFY THAT 1 HAVE 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.
DATE COMPLETED: ✓ tklA I
PRINT NAME; JvaH • ' ' as
SIGNATURE:
ADDRESS OF APPL CANT: 3 (Q�� f �y /
CITY, STATE, AND ZIP CODE: (( 4W44 I'at "'J LM qi % f�
PHONE: DAY �OI1 I" t /O FAX NUMBER: COM--q Q 1 I0S%
CONTACT PERSON ON THE DAY OF THE EVENT: Aaim Mien
i en
PHONE: WO (i 0-f _7&4" CELL: (Ii. 2•31 —VP & 6
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.
Publie WOD(S Staff Only -
aortal Amot:m Received: Reuipr Number;
Deposit Amount: Deposit/ Key Returned:
Check Key issued: YES NO
619 409 7688
02:19:45 p.m. 08-02-2011
Safety/ Security
Please describe your procedures for crowd control and internal security:
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e O!'1 hand - -d dirad. p(-ici r+rl-5 7t votriostAs
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porr�at� � a�Ty++� tut �O� .�wfr�+ 4s
'ej atropin perra4
YES NO Have you hired any Professional Security organization to handle
Security arrangements for this event? 1f YES, please list:
Security Organization:
Security Organization Address:
Security Director (Name): Phone:
4 /9
i
l619 409 7688
02:20:26 p.m.
08-02-2011
DAIROYUDOWYYYI
C9R ME
INSURANCENCCHAMl 09 23 10
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIGN
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURANCE
pR - CERTIFICATE OF LIABILITY
R
TVateridga Inanranoe Services
10717 Sorrento Valley Rd.
San Diego CA 92121
Phone:858-452-2200 Fax:858-452-6004
INSURERS AFFORDING COVERAGE
RJEURERA' Palau xaiwa Camp.OY ar Marta.
INSURER D.
National City Chamber o
oNerCp; mile of Car O. ... -.
901 NatienAl City Sou vats!
National City CA 9195
COVERAGES _ _...
WEDABOPEFORTNE OLICYSERICMI DWATETL EE NOTWITHETN
THE REQUIRE ENT.T TERM
CONDITION
lF HMGNCBERN ONTRACT
OR TGLNEIDCUMESURED NWMABSPECT OYBKM THIS
E IFICATE T MAY
8€ ISSUED -
AAYPERT IN.THEI sun Nc AFF RIDN OF ANY CONTRASTOR RIBER OOGUMESS
MAYPERTAIN_TNE INSURSHPORDEODYTNEPOLIGIESDESCW&EDiER91N IS SUBJECT TOAD-117ETERUS.E%CLVSIONS;Nm ONLIMONS OF SUCH
____
RAVE BEEN REDUCED BY PAS) MAIMS. '
POLICIES. AGOREOATE LIMITS RHCYYINN MAi r1AS9g91R} DATE I. .. DATE R
nEMwI�IIT'F.ITS�
GENERAAAMUTY
C6WM RC(MOENRRALLvmnHY PA838912516
CLAMS BYM W OCCUR
.
OENLAG=SOATE UMITAPPNIESPER.
is POLICY ■ JB& ■ LOG
AUTOMOBILE UAWIUTY
Mil AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
NIREOAUTOS
NON -OWNED AUTOS
DEDUCTIBLE
RETENTION S
WORKERS YERS' UASLSA ION AND
EMPLO
OFF10ERMEMSERREE�UDED/ ECUTNE
Dyes dassn:a urMar
SPEGI I R PROVISIONS balers
PAS38912516
O9/22/10 09/22/11.
PREMISES - pacaeews))
MED FXP es, tempt/ma
PERSONAL 4 ADV INJURY
GENERAL AGGREGATE
PRODUCTS-CDLY/OP AGO
COMBINED SINGLE UMJT
09/22/10 09/22/11 _..
BODILY IDURY
(Par amen)
s2 000 000
$2,000,000
sl0 000
s2 000 000
s4,000 000
41,000,000
6i9
1111111
GDORYMJURY
((PM Pda9aTMm14wuIGE
101111
EAAC�
OTHER THAN AUTO ONLY. BOG
uJSOHENG!
TORY UMITS
E.L EACH ACCIDENT
F.-C. DISEASE- EA EMPLOYEE
E.6=EASE- POLICY LNL
CSyi.ATION FOR LION -PAYMENT OE PREMIUM. THE CITY
DES CE-P OF 0—DAY SI LOCATIONS l VEMICLEANCEEXCLUSIONS
LATIO II) a n NONJ,ERTfB .
OF NATT NAL CIT NOTICE Ott CAN BOARDS, COMMISSIONS, EMPLOTEEs, AGENTS AND
OF NATIONAL. CAS ITS RESPECTIVE
OFFICIALS, NAMED ADDITIONAL
CONTRACTORS, AS THEIR RESPECTIVE INTERESTS MAY APPEAR ARE
INSURED
/UZSLOCATED PECT TO ENIRLMLIABILITMIER TS ATTACHEF NATDNALD VG2012CIT0 /09. REI NOD
INSUREDrS
CERTIFICATE HOLDER
CITY OF NATIONAL CITY
1243 ONAL CITY BLVD.
NATIONAL I CITY CA 92050
ACORD 26 (2001/08)
NAT1002
Er'ANCELLA _. ETHE ERMATNON
SRDULOANY 0F THE ABOVE DESCRIBED POLICIES BE CAF7 3BEFOR GAYSXPJR II
DATE THEREON; THEISSUING INSURERWILL ENDIAYO LTA
MAR NEN
OTI9E TO THE CERTIFICATE HO[OER NAMED TWERP LEFT,T1UTYRJLMRE'-:O �NALR
1100:FHDOBUBATWHl�H
NBIRLIABIL YORAWOHPDR3RE-MURER.aElk
+0 AGGRO CORPORATION 1988
EL19 409 7688
INSURE['$ MAME #ititimial City Chamber :o:,
NAMED PNSURED SCHSDULE READ$ AS FOLLQW5: -
NATIONAL CITY CHAMBER OF COMMERCE
MILE OF CARS ASSOCIATION
7 i9
02:21:02 p.m. 08-02-2011
@AGE. 2:.:
bATR: .0/23/310:
siii619 409 7688
02:2i:18 p.m. 08-02-2011
8/9
NATIONAL CITY CHAMBER OF 0011118808
POLICY NUMBER: pAs38912516
COMMERCIAL GENERAL LIAB
ILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - STATE OR GOVERNMENTAL
AGENCY OR SUBDIVISION OR POLITICAL
SUBDIVISION - PERMITS S OR AUTHORIZATIONS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
ata
o Or Governmental Agency Or Subdivision Or Political Subdivision:
AS REQUESTED BY WRITTEN CONTRACT
Information required to tom
Section 11 — Who Is An insured Is amended tenih-
clude as an insured any state or g
thtal
eSchedule, subject to thelitical following provsubdivisisions:
on shown i�
isio s
e
1. This insurance applies only with respect to opera-
tions performed by you or on your behalf for which
the state or agency
political subdiWaon hasl issued or apermit or - au-
thorization.
fete this Schedule, if not shown above: will be shown in the Declarations.
2, This insurance does not apply to:
a, "Bodily injury" "property damage" or "personal
advertisingand
perfo med r the federal s gove government, state of
municipality; or included
b. "Bodily injury' or "property damage'
within the "products -completed operations
hazard".
CG 2012 OS 09 0 !nsurence Services Office, Inc., 2008
Page 1 of 1 0
0619 409 7688
RUC-2-2011 12138 FROM:
win 4007ttei
02:21:40 p.m.
TO:1619409768B
4t:5204 an. *Safi
08-02-2011 9 /9
P,2/2
C {OFNATIONAL yCITY
P'. ?FS1 f USE BOLO HARMAN
CATION AG2Enla
Person requesting use of City
minimum of $1,000,000 combl
damage which include the ci'
insured and to sign the hold
smelted to this permit.
. facilities or peracOmi are wilted to mot de a
single limit insurance for bodily injury and pry
ofliciats. agents mid employees named as additional
less agreement, Cerdficato of inairrteme+must be
�e3t n, A Z2) (pi elk ft fr hit' 0r male rLu & the
Person in rgeofactivity „.. m i l
Addle:
Telephone: ��"iv i`0 - gala at14244. aIIan Pj •o4 o
City Facilities and/ or property
j r�
rY114vtivl j thir tIt.
Data)ofuse: i K�r t% az it
HOLD HARMLESS AGE
As a condition of the issuance
On public or privet pmpotty,
hold hannku the City of iV
against any endati cbanma,
injury, death, or property de
attorneys fees and the coats of
property or the activity takes
aoneectera.
g
Certificate of insurance Approv
a temporary ice permit to conduct its activities
trnda+sianod hereby arc® to deiced, indemnify and
I City and its officers, employees and agate from and
costs, Sacs, liability er damages for any peraenal
-- botft, or any frtipadon and other liability. including
Sim, arising out or mimed to the is of public
the permit by the pemtit or Ks agents. employees or
Banc n
Caeswe(n freinehlre
res ;Alen # 7eCO
Name and Title
Martin Luther King Community Center
140 E. 12th Street
National City, Ca. 91950
Set up: Organization: .. . ^' U&
Date: Sztpt t s t a.o t t
Times: 2 AM — a �,r,
New eieuA>
?, ► _--� L _l Exit
FUP FEE WORKSHEET
(MLK, RECS, KSC/CASA, NUTRITION)
Event/Group Name:
Sen. Juan Vargas
Resident?
50%
Date(s) Rqst'd:
9/15/2011 ((Thursday)
Facility: MLK
Time of Event:
8 a.m. to 2 p.m.
#Hours: 6
# People:
250
Frequency:
One Time:
X
ShortTerm:
On -Going:
Council Date:
9/6/11
at 6:oopm in Council Chambers at City Hall
RENTAL RATES
Hourly Rates
Total
MLK (for dining)
People
South
North
Entire
gn
Charge
Notes
0-73
$23.45
n/a
n/a
$0.00
73-149
n/a
$70.36
n/a
$0.00
150-221
n/a
$87.97
n/a
$0.00
222-294
n/a
n/a
$117.26
$0.00
MLK (dance/assembly)
0-100
$23.45
n/a
n/a
$0.00
101-157
$29.32
n/a
n/a
$0.00
158-300
n/a
$70.36
n/a
6
$422.16
301-472
n/a
$87.95
n/a
$0.00
472-630
. n/a
n/a
$117.26
$0.00
Rec. Centers & Casa
varies
---
---
$23.45
$0.00
Kimball Senior Center
0-149
---
---
$70.36
$0.00
150-221
---
---
$87.97
$0.00
Service Clubs Only
$100.00
per month
Months:
$0.00
KITCHEN ($50 min)
$10.00
per hour
Hours:
$0.00
FAC/BLDG USE FEE
$50.00
1
$50.00
CUSTODIAL• (Dep/PW)
Rate
Duration
$22/hr reg, or $35/hr OT
$22.00
$0.00
Setup/Cleanup time
$22/hr reg, or $35/hr OT
$22.00
6
$132.00
1-100(2hr), 101-157(4hr), 158-300(6hr), 301-472(8hr), 473-630(10hr)
CSD STAFF(Dep/CSD)
$11.00
per hour
Hours:
$0.00
EQUIP: chairs:
$0.75
each
Qty:
260
$195.00
tables:
$1.00
each
Qty:
3
$3.00
TOTAL FEES
$802.16
DEPOSITS
Kitchen:
$60.00
Refundable
$0.00
Cleaning
$100.00
Refundable
1
$100.00.
Key Deposit
$100.00
Refundable
$0.00
Total Deposits:
$100.00-
ACCOUNTING:
$472.16
001-22000-3634
$132.00
626-422-223-102
$198.00
626-00000-3634
$802.16
Fees/Council Date reviewed/confirmed
with: Date:
Note:
MIS for projector, screen, cables for PowerPoint presentation. Microphones.
Stage: Podium and microphone on left side, set up 2 8-ft tables with 3 chairs each.
Main Corridor: 8-ft table with 2 chairs for sign in
Set up 250 chairs theater style with aisle in middle