HomeMy WebLinkAboutFacility Use Application*- CALIFORNIA.-
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City of National City
Facility Use Application
Rev. 10/18/11
2100 Hoover Avenue
National City, CA 91950
(619)336-4580
Fax (619)336-4593
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 ansr anguestjns from
The City Council t_
Facility Requested: please circle
Martin Luther King Jr. Building
North Room South Roo
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Date(s) of Use: April 20-21, 2012 Day(s) of Use: _Friday & Saturday
April 20 from 9AM to 5PM April 21
Time of Use: From: 6AM AM/PM To. 8pm AM/PM — INCLUDE SET-UP & CLEAN UP TIME
cenut 4/4-lha- 7AP-SPIA fr-t.ueau St Cre: elks.,lid- Sfria
Type of Function/Activity: SD Dia de la Miner Latina Health Festival Is the event open to the public? Yes
Name & Address of Organization/Group: MANA de San Diego 2515 Camino del Rio S, Ste. 228, San Diego, 92108
Non- profit organization: Yes No Tax ID # 33-0821060
Anticipated Maximum Attendance: 700 Percentage of National City Residents 70%
Will Admission be charged? No Amount $ Will this be a Fund Raising Event? No
Equipment Requested: 400 (all)_ # of chairs 30 (all) # of banquet tables No Stage
Yes Podium/Microphone
No Audio & Visual Equipment Required? (Please Specify)
**PLEASE ATTACH SEATING DIAGRAM
Use of Kitchen: X Yes No Use of Gas for Range and Oven: Yes X No
Is the Use of Alcohol Requested? No
Will other paid services be used (I. e, commercial caterer, DJ, Band, etc)? Yes No No
Name:
Name:
Phone:
Phone:
How many times in the last twelve months have you requested to use a City Facility? _1_
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 PROVISION.
DATE COMPLETED: I le —
PRINT NAME: Sofia Salgado
SIGNATURE:
ADDRESS OF APPLICANT: 251 del Rio South, Suite 228
CITY, STATE, AND ZIP CODE: San Diego CA 92108
PHONE: DAY 619.297.0115 FAX NUMBER: 619.297.0996
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: Sofia Salgado or Ana Navarro cell: 619.895.1288
PHONE: (619) 297-0115 CELL: (619) 743-1604
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. MANA de San Diego
Person in charge of activity: Sofia Salgado
Address: 2515 Camino del Rio South, Suite 228, San Diego, CA 92108
Telephone: (619) 297-0115 E-Mail: ssalgado@manasd.org
City Facilities and/ or property requested: MLK Community Center, Recreation Cener
and Kimball Senior Center
Date(s) of use: 4/20 and 4/21, 2011
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.
Signature of appli
Certificate of Insurance Approved by
Date
Name and Title