HomeMy WebLinkAboutFacility Use ApplicationCALIFORNIA -rt
Today's Date:
Name:
Address:
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MCORPOB"TIM l
Public Works Department
2100 Hoover Avenue National City, CA 91950
(619) 336-4580 Fax (619) 336-4594
www.nationalcityca.gov
Applicant Information
(Please be sure to print in blue or black ink)
10/01/1012.
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Organization: RE1YukA) AtiERicA
20 N. RAY OND AVE- f xO
City/ State/ Zip: Pie/SAMNA CA. q 1103
Phone: ‘26 ` 3S6•go5Contact:
Field / Facility / Park Requested
Please check all that apply:
El Toyon Park Kimball Park Las Palmas Park
Sweetwater Heights Park Camacho Gym Pool
El Toyon Rec. Ctr. Kimball Rec. Ctr Camacho Rec. Ctr
Casa De Salud Lf Kimball Senior Centre Nutrition Center
NONE
Audio & Visual Equipment Required? (Please Specify)
Activity
Please circle appropriate activity:
Astrojump Meeting Room Athletic Field rental* Baseball* Football*
Softball* Volleyball* Basketball* Tennis* Soccer* Picnic
Swimming [f'
Other FAM I Wy ` VN EVENT
*If reserved for league play, you must submit a team roster with addresses within 10 working days.
Amount: Date Paid: / / Initials:
Field / Facility Information
Dates requested: t t / 1 t /20 1 to I / /2017, ONE PAY 001X.
Days of the Week and Hours requested
Days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
From:
12:00
To :
16:30
4..5 ROI
Total
q0 number of participants at your event .„r0 % of participants National City residents
Requesting Organization:
Name:
Field / Facility Request Form Checklist
reoinzo OsAM
Please initial all sections of this checklist:
Field / Facility Request Form
TO Current Insurance Certificate
Current Audited Financial Statement
Current Roster Data
(By 2nd Game of Season)
Date: 10 / 12
Hold Harmless / indemnification
Current Organization's Bylaws
Preliminary Roster Data
Received Copy of City Council Policy 801
Public Property Use Hold Harmless and Indemnification Agreements
Person's requesting use of City property, facilities or personal are required to provide a minimum of S1,000,000
Combined single limit insurance for bodily injury and property damage which include the city, it's officials, agents
And employees named as additional insured and to sign the Hold Harmless Agreement, Certificate of Insurance must be attached
to this Permit.
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 cost of litigation, arising out of or related to the use of
public property or to the activity taken under the permit by the permitee or its agents, employees or contractors.
Signature:
I have read and completed the above form to the best of my knowledge
Public Works Department Staff Use Only
/ p/ / 2CJ/ 2
Verified By: Date: ! /
PRINT NAME
Signature:
FOR DEPARTMENT USE ONLY
PARK DIVISION APPROVAL: YES NO DATE: I !
COMMUNITY SERVICES APPROVAL: YES NO DATE: / /
NOTE; ALCOHOLIC BEVERAGES / SMOKING BANNED IN
ALL FIELDS / FACILITIES/ PARK
Revised 6/28/1 ]