HomeMy WebLinkAboutField/Facility/Park Use Application_-. CA.3FORN!Et
NATIO N.L...r:r,
Public Works Department
2100 Hoover Avenue National City, CA 91950
(619) 336-4580 Fax (619) 336-4594
www.nationalcitvca.gov
Applicant Information
(Please be sure to print in blue or black ink)
Today's Date: 11 /Jun I2013
Name: Samuel Gonzales Organization: NFL PLAY 60
Address: 2106 "C" Avenue
City/ State/ Zip: National City, California 91950
Phone: (619)250-5904 Contact: Samuel Gonzales
Field / Facility / Park Requested
Please check all that apply:
El Toyon Park Field/Turf Kimball Park Las Palmas Park
Sweetwater Heights Park Camacho Gym Pool
El Toyon Rec. Ctr. Kimball Rec. Ctr Camacho Rec. Ctr
Casa De Salud Kimball Senior Centre Nutrition Center
Audio & Visual Equipment Required? (Please Specify)
Activity
Please circle appropriate activity:
Astrojump Meeting Room Athletic Field rental* Baseball* Ft 11*
Softball* Volleyball* Basketball* Tennis* Soccer* Picnic
Swimming
Other
*If reserved for league play, you must submit a team roster with addresses within 10 working days.
Amount, Ca Q Date Paid: / / Initials:
Field / Facility Information
Dates requested: 17/ Jun/2013 to 18/Junr2o 13
Days of the Week and Hours requested
Days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
From:
8am
Sam
To :
2pm
2nm
Total
C., ill's
to hrs
300 number of participants at your event 80 % of participants National City residents
Field / Facility Request Form Checklist
Requesting Organization: NFL PLAY 60 Character Camp
Name: SatleWanzales Date: 11/Jun 2013
Please initial all sections of this checklist:
X Field / Facility Request Form X Hold Harmless / Indemnification
X Current Insurance Certificate
Current Audited Financial Statement
Current Roster Data
(By 2' Game of Season)
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 $1,000,000
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.
I have read and completed the above form to the best of my knowledge
signature: Samuel I. Gonzales Date: 11/ June /2013
info@ncdiablos.com
Department of Public Works Staff Use Only
Verified By:
Signature:
+ did
PRINT N
�r 1
FOR DEPARTMENT SE ONLY
Date: OG l I L 113
PARK DIVISION APPROVAL: YES NO DATE: / /
PUBLIC WORKS APPROVAL: YES NO DATE: / /
NOTE; ALCOHOLIC BEVERAGES / SMOKING BANNED IN
ALL FIELDS / FACILITIES/ PARK
Revised G/28/11