HomeMy WebLinkAboutFacility Use ApplicationCAUFORNtA -,
NATIONAL C11
cORPORAT
City of National City
Facility Use Application
Rev.6128/11
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,juestions from
the City Council.
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Facility Requested: please circle
Martin Luther King Jr. Building
North Room [South Room) Entire Facility
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Date(s) of Use: CCLJ e.; q-e
Time of Use: From: f J?t-/ r
Day(s) of Use: j i.,t f-- 4cL S
M To: i f 3O AM INCLUDE SET-UP & CLEAN UP TIME
Type of Function/Activity: 1 ec, jtj � 1,-2c.:s Is the event open to the public? ` 91.)17 b on
Name & Address of Organization/Group: /`1„41'707 2- .C.t `/J?
Non- profit organization
No `I'Tax ID # it--46>4-1 734._.
Anticipated Maximum Attendance: 20 -25T 'Percentage of National City Residents 33%
Will Admission be charged? kJ 0 Amount $ T--- Will this be a Fund Raising Event? 0
Equipment Requested: 3 e # of chairs # of banquet tables , c Stage
icrophone
**PLEASE ATTACH SEATING DIAGRAM
Audio & Visual Equipment Required? (Please Specify)
Use of Kitchen: Yes No Use of Gas for Range and Oven:
Is the Use of Alcohol Requested? A) c.
Will other paid services be used (I. e, commercial caterer, DJ, Band, etc)? ,/ Yes
Name: i p y c f T1\
Name:
Phone: 6l9' — 4129-- 97,57
Phone:
Yes X' No
No
How many times in the last twelve months have ou requested to use a City Facility?
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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.
DATE COMPLETED: '7 — 13
PRINT NAME: i?:47—
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SIGNATURE:
ADDRESS OF APPLIC : L 10ZC
CITY, STATE, AND ZIP CODE: /r /ire e) C QZ l3'y
PHONE: DAYg5/ fl 6/7- / FAX NUMBER: 5.J,47/- q/Z
CONTACT PERSON ON THE DAY OF THE EVENT: CLu-b
PHONE: t' ' ?J /Z CELL: €/T
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:
07G'oC (g)),0 dc11
Person in charge of activity:
C7A0-4--ser
Address: 1 I '2-Comic. U)Cc-0 L -4t Sez✓I % // 5,j -.2i: -Y
Telephone: k, Gy) q 7- {7 or- E-Mail: Jccrsa-o ifybcri, ear,/
City Facilities and/ or property requested: h'l SattA %G
Date(s) of use: Tuecleizi f)ciju
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.
Signa plicant Date
S Certificate of Insurance Approved by
Safety/ Security
Please describe your procedures for crowd control and internal security:
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/i cafe Q (uex 1Y2
1
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:
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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: SU6r �!
Contact phone number be day of event:
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: