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City of National City
Facility Use Application
Rev.6/28/11
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
Martin Luther King Jr. Buildin
North Room South Room Entire Facility
Date(s) of Use: % uSC1CJj 0461aor3lacIaDay(s) of Use: lr InIkh➢Sr�Qz1 Oelobv 4 &OI a
Time of Use: From it 0 Q (/PM To: 3 10 0 AM i - INCLUDE SETUP & CLEAN UP TIME
Type of Function/Activity$Q106_40 LktVki Lira[Qi{ Is the event open to the public?
Name & Address of Organization/Group4 eee, Oaf unc6akto ' 1 Bkvd , k)°9 Hs()
Non- profit organi7ation(Yes) No Tax ID # 95- iQ38 MS --
Anticipated
Maximum Attendance:C
�1JC� Percentage of National City Residents '� v 6
Will Admission be charged? Ycg Amount $ 5 0 Will this be a Fund Raising Event? Ni0
Equipment Requested: 350 # of chairs # of banquet tables QS 0
X
Podium/Microphone
Audio & Visual Equi
Lopiop, rcp-clown 5crazr
Use of Kitchen: X Yes No
**PLEASE ATTACH SEATING DIAGRAM
ment Required? (Please Specify)
Ism- - pW9S In-10 nVl ---fob F(,Q)1.{iraoph»no
Use of Gas for Range and Oven: X Yes
Is the Use of Alcohol Requested? NO
Will other paid services be used (I. e, c ercial cater, , D
414rP Name: tJ krwWin 4-I' ftia 4-;me
Name: Navi13an4 Sv„h)west— or Phone:
Svi-I,t Bart(''
Phone:
tc)? )( Yes 1,
No
DATE COMPLETED:
How many times in the last twelve months have you requested to use a City Facility.? M QV Oil Take pc
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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
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.
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PRINT NAMEZ-O.CC'1111A 1 / 9 ROC-0
SIGNATURE: l t� y�
ADDRESS OF APPLICANT: Qd� !,i[><}Iotai I Cd'1 j�j1Vf1.
CITY, STATE, AND ZIP CODE: kitIllbeat CA. 91g50
PHONE: DA` 0111 -I11'153E1 FAX NUMBER:OA 41l —SO14
CONTACT PERSON ON THE DAY OF THE EVENpT:T1c OflI'l)UAQi�d_
PHONE: (1,4r4 4`11—559 CELL: (pfj)11 to -61014
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.
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: -(}
Person in charge oof_activity:
A`iacy.o;(}k_'tr 1\11Ar 0Q
Address: 10 14�X]tl� 10k01 ?.149 e)1uI(\ U l' 119_.' o 1 '.'
Telephone(kijI 1- !J7 I E-Mail: �,vro,`o (1 Qe* wf\i e1ttl1 �'11111W�1.0
City Facilities and/�"or property requested: Li I K C6U m )3T i4 Q�
V\\1 111
Date(s) of use: vK(iLt . O�CJ tj` 3 I ama_
C � Qlealtir bon
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.
Signs -ppl
Da e
Certificate of Insurance Approved by
Name and Title
Safety/ Security
Please describe your procedures for crowd control and internal security:
CS* c3k (x V AOkiWAQ v\A U U 6 (m ron
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 • ed to persons 21
years of age or older. The designated alcohol server must also be years of age or older.
Name:
Contact phone number
day of event:
YES NO Have you hired any Profess' s al Security organization to handle
Security arrangements for t ' event? If YES, please List:
Security Organization:
Security Organization ddress:
Security
ctor (Name): Phone: