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Home My WebLink AboutFacility Use Application4T • L-6"-rje 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 APPLICAIV'TS: It is strongly recommended that an applicant requesting use o6 City Facility attend the City Council meeting when the item is scheduled for consideration in order to answeEny crilestial from the City Council. c fn -v 0 cn Cl rn -t� Facility Requested: please circle Martin Luther King Jr. Building North Room South Room Date(s) of Use: I -- C �Day(s) of Use: Time of Use: From` W'�� ' M J To: -Lbcay 66L-Y1 -Q w w cr INCLUDESET-UP & CLEAN UP TIME Type of Function./Activity1t 4- Tbc4T J5t (hL�tZ 1 Is the event open to the public? 1'1 D Name & Address of Organization/Group:�. r LY J (L t 1 (1&m l-- 5 Non- profit organizatio . Yes No Tax ID # f Anticipated Maximum Attendance: q Percentage of National City Residents 166 Will Admission be charged? \ 1) Amount $ Will this be a Fund Raising Event? YI d Equipment Requested: IS- # of chairs 6# of banquet tables Ni-A Podium/Microphone Stage **PLEASE ATTACH SEATING DIAGRAM Audio & Visual Equipment Required? (Please Specify) Use o ' 'tchen: , - Yes/ No Use of Gas for Range and Oven: Is the Use of Alcohol Requested? rv) Will other paid services be used (I. e, commercial caterer, DJ, Band, etc)? Yes Yes No Name: Name: Phone: Phone: No 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 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 I07.6 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: PRINT NAME: C` SIGNATURE:�(f� ADDRESS OF APPLICANT: I $1 -elinhALY` et'LL U4' C �.V1 13 CITY, STATE, AND ZIP CODE: PHONE: DAY t o vi L FAX 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: IrCL) &I I U'C... a PHONE { `l l r CELL:01 569. ��JJ 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: City Facilities andf or property requested: M L( Date(s) of use: 1 2_ 22--2-b l HOLD HARMLESS AGREEMENT NRS' DYICki ij 1112nDUSLi- Person in charge of activity: ' _cc_ Cife.AI D YYl l cSi( `Z 1 Address: Y1'1 . �`5 L Ntekia, J� 1 ql ' 1 Telephone: (0I61-' i"Z.J t E-Mail: 6 v do rni YiDi + ' 2-3} / . 0YY) ;l L/ 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 applicant r0 Certificate of Insurance Approved by 91L9/17_- Date Name and Title Safety/ Security Please describe your procedures for crowd control and internal security: \ 5 LfLtit,b f11Q u3 CC Y\ �` '- +1) try4VA, t ! )31- ji ii.Qsr) in 6e.L12.cl Lam. zf -1-D 6 winet iY001075 '01,5 S 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: 4 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: North Hall Exit Exit Exit Martin Luther King Community Center 140 E. 12th Street National City, Ca. 91950 71 ft South East 65 ft North West [78 Exit Exit Exit Entrance — Two Double Doors Occupancy: Dance 470 Dine 225 South Hall Martin Luther King Community Center 140 E. 12th Street National City, Ca. 91950 South East North West i---) Exit 25 ft 4 Exit 67 Ft Entrance Double Doors Occupancy: Dance 160 Dine 75