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HomeMy WebLinkAboutFacility Use ApplicationCity of National City Facility Use Application Rev. 10/18/11 -73 r" r- CD G7 N Fri '9 2100 Hoofer AveEhe National Cty, CAF9195 (619)336-4580 Fax (619)3Y6-4593 z7) TO ALL APPLICANTS: It is strongly recommended that an applicant requesting use a CityTacility3 attend The City Council meeting when the item is scheduled for consideration in order to answ any testhfls from The City Council ` Facility Requested: please circle Martin Luther King Jr. Building North Room South Room Entire Facility -B u� Date(s) of Use: pa_ f I `UT f ° sii; r Day(s) of Use: 'V-Lt Ma Time of Use: From: DWI AM/PM To: 1 '?f'+'1 AM/PM — INCLUDE SET-UP & CLEAN UP TIME Type of Function/Activity: * ot a it-heit-he UV (W//Uj 4s the event open to the public? ve 4 Name & Address of Organization/Group: Ki-C• COUO'C OZ y t4 au h Non- profit organization: No Tax ID # 2-1 I S 2 &'LO I 3 kelAnticipated Maximum Attendance: 300 350 Percentage of National City Residents 10070 C4O(d� Wi11 Admission be charged? N © Amount $__ Wi11 this be a Fund Raising Event? Equipment Requested: 20 # of chairs 2 0 # of banquet tables 1 Stage Podium/Microphone **PLEASE ATTACH SEATING DIAGRAM Audio & Visual Equipment Required? (Please Specify) Use of Kitchen: Yes / No Use of Gas for Range and Oven: Yes 7 No Is the Use of Alcohol Requested? t+1 Will other paid services be used (I. e, commercial caterer, DJ, Band, etc)? Yes i No Name jUfl C 1thar4 Phone: UK* L11 t1- 011 Name: juilC 604Na Phone: OK 414 (!1jt) How 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 Public Works 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 FOR THE FACILITY REQUESTED, AND I AGREE FOR MY ORGANIZATION/ GROUP TO CONFORM TO ALL OF ITS PR�OVISIION. DATE COMPLETED: NOV. 1'is'J fa PRINT NAME: (TA e ��%�d ile:th ADDRESS OF APPLICANT: J t'jU/Rf� Pm CI -- CITY, STATE, AND ZIP CODE: N-li_ / Calf. elf4R7 PHONE: DAYa/4 "11�t1'07' X NUMBER: 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. CONTACT PERSON ON THE DAY OF THE EVENT: s,Jlheil e' sew/vied/1 PHONE: ag 1414 ' 0111 CELL 401- cP3a-i Public Works Staff Only - Rental Amount Received: Receipt Number: Deposit Amount: Deposit/ Key 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. Organization: i(-C- cb(cye actrig Uot% C&b Person in charge of activity: Tithe- Gzt tuttlei Address: 6 W t 1em Gtheof-Lk C. CA qtq/ U Telephone: (,Q - Hit- 04711 E-Mail: CPI net- T--otim,94 fCP13rra ?ow-, City Facilities and/ or property requested: H LK Date(s) of use: Pe - 11f 1f 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. Novi- /O, 2011 ignature of applicant Date Certificate of Insurance Approved by Name and Title Safety/ Security Please describe your procedures for crowd control and internal security: vat& wiU cif- with Fire f1 efier aw vctunferc ay w � a� -me sire Marm-al( who mil -Waite With crowd contro/. rani [i e4 m it [Hew cw4&e and cane i n bnt 479 ote. 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: Vift lvpic6til C 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: