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City of NationalCity
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 iE, order to answer any questions from
the City Council.
Facility Requested: please circle
actin Luther Kin • Jr, BuilclingD,
orth Room South Room r9
o rc n0dItdcv
Date(s) of Use:
Time of Use: From: 800
(l". tlitY I + t9O Day(s) of Use; t ecl 111 `, f�C' 4)r-1 t &JJ �-}
M To: 3' OG At�rl 'lvf - INCLUDE SET-UP & CLEAN UP TIME
Type of Fun ction/ActivitythIVAI -to %OUki LUr Qhean
Name & Address of Organization/Group: etIN IkCi011.10tC e4111rriQiC91 CIO kkcifiord (t .tqt91950
Non- profit organization
Anticipated Maximum Attendance: .260
Is the event open to the public?
No Tax ID# -10M31
Percentage of National City Residents 1.5 eio
Will Admission be charged? dl$ Amount $ 50 Will this be a Fund Raising Event? NO
Equipment Requested: 35 0
\es Cod iucn/iviicrophonj
`' Audio & Visual Equipment Required? (Please Specify)—
# of chairs Cray ia3)
# of banquet tables
6i'I9S
**PLEASE ATTACH SEATING DIAGRAM
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flrop-Down vn sac , set
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Use of Kitchen: X Yes No Use of Gas for Range and Oven: X Yes No
Is the Use of Alcohol Requested? N 0
Will other paid services be used (I. e(commercial catere DJ, 'and ete)? X Yes No
Name: UWft 4` 1 }1a
Naine:.-&t - (Awful 61-1-4 i i-fifi7�
Phone;
Phone:
How inany tines in the last twelve months have you requested to use a City Facitity?__
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 farther 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 TIIAT I HAVE RECEIVED A COP OF THE RULES AND REGULATIONS FOR
THE FACILITY REQUESTED, AND I AGREE FOR MY ORGANIZATION/ GROUP TO
CONFORM TO ALL OF ITS ' RO /SION.
DATE COMPLETED:--��
PRINT NAME: z3
SIGNATURE:
ADDRESS 01 APPLICANT: 901 Lahak0
exk'itd.
CITY, STATE, AND ZIP CODE:ybhtl t'x�u; 1
PHONE: DA'l (tlril t r-9B39 FAX NUNBER:4619 r- 0i8
CONTACT PERSON ON THE DAY OF THE EVENT: U h i11j)
EH ONE: IA4�11` 9 CELL: (Jf 8qo-6{ 14
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-
Renial Amount Received: Receipt Number.
Deposit Amount: Deposit/Key Returned:
Check Key issued: YES NO
TeIephone( t 1)t fli — 2)M9 E-Mail:
City Facilities and/ or property requested: IkALK Ca1`V'11Y1 n N4tkr'
Date(s) of use: drttatIC { O(400er 1, 61_(} 14
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: c 1t3 bxv co
Person in charge of activity: 3 _Cstp 1 }M
Address:90 1 i Okk ith Blvd. , nJ , CA, t o
I I'
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.
Sigke /fappij4i
Certificate of insurance Approved by
Name and Title
Safety/ Security
Please describe your procedures for crowd control and internal security:
flt [ ( 1 4 i t •, i i • 1 iti
' tY�1 C1, r
LLt i1 1 -.
YES A NO Have you hired any Professional Security organization to handle
Security arrangements for this event? If YES, please ist:
Security Organization: `e c0;d ,1 ` o "
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 se d to persons 21
years of age or older. The designated alcohol server must also be 2 ears of age or older,
Name:
Contact phone number the day of event:
YES NO Have you hired any Profes '.nal Security organization to handle
Security arrangements for t''s event? If YES, please list:
Security Organization:
•Security Organizsti�ceA.ddress:
Securit 6-irector (Name): .Phone:
Salute to Navy Luncheon
WednesdayriOctober 1, 2014
Additional Requests:
9 6- 6 foot tables {will be used for the registration, sailor's hats, goodie bags, sponsors, etc.)
> Stage riser inside the bunquei IFuli
Poc dim
9 City Signage:
a) The use of the entire porkiny lot tit the MLK Community Center
b) No ticketing in and around surrounding areas of the MLK Community Center
c) No street sweeping in and c round surrounding areas of the MLK Cornmunity Center
d) Parking signage along 12th street informing the residents of the event taking place on
Wednesday, October 1, 2014
9 The use of the screens inside the MLK Community Center announcing the event a few
weeks prior to the event and providing a slide show when guests arrive to the luncheon
9 Hang Banners (along National City Blvd, Inside the MLK Center and outside the MLK
Center)
9 Decor of MLK Center Hall
9 Access 1 day prior to event for set-up
FUP FEE WORKSHEET
(MLK, RECS, KSCICASA, NUTRITION}
Event/Group Name:
"Salute to the Navy", NC Chamber of Commerce
Resident? :Yes
Date(s) Rgst'd:
Wednesday, October 1, 2014
Facility: MLK
Time of Event:
Frequency:
Council Date:
8:00am - 3:00pm
# Hours: 7
# People: ':350
One Time:
X
Short i erm: 1
On -Going:
August 19th
at 6:00pm in Council Chambers at City Hall
RENTAL RATES
Hourly Rates
Total
MLK (for dining)
People
South
North
Entire
Qty
Charqe
Notes
0-73
$23.45I
n/a
nla
$0.00
73-149
nla
$70.36
me
$0.00
l
150-221
222-294
rite._
n/a
$87.97
nia
$0.00
l
MLK (dance/assembly)
n/a
$117.26
7
$820.82
_..
0-100
101-157
$23.45
$29.32
n/a
n/a
nla
1
$0,00
n/a
$0.00
158-300
nla
$70.36
n/a
$0.00
301-472
n/a
L ntafi
---
---
---
$100.00
$10.00 jper
$87.95
n/a
--
--
per month
hour 1
n/a
$0.00
r
472-630
Rec. Centers & Casa varies I
$117.26
$0.00
$23,45
$70.36
$0.00
L
Kimball Senior Center
Service Clubs Only
0-149
150-221
$50 00
$22/hr reg, or
.
$0.00
$87.97
Months:
�, $0.00
$0.00
KITCHEN ($50 min)
Hours: 5 $50.00
FAC113LDG USE FEE
1 $50.00
CUSTODIAL (DeptPW1
$351hr OT
r
I Rate
$154.00
Duration
I $22.00: 7
Setup/Cleanup time ,$22/hr reg, or $35/hr OT
L i $22.00I 8 $176,00
1-100(2hr), 101-157(4hr), 158-300(6hr), 301-472(8hr), 473-630(10hr)
CSD STAFFfDep/CSD1 $11.00 per hour
r
Hours:
$0.00
i
EQUIP: chairs:
$0.75
$1.00
$60.00
$100 00
$100.00
each I-
each
Refundable
Refundable
Refundable
r.__.- _.-_-.
F l
_ __-- . ----
Qty:
Qty:
350 $262,50
t
tables:
TOTAL FEES
35 $35.00
$1,548.32
DEPOSITS
1
$60,00
$100.00
- -
Kitchen:
Cleaning
Key Deposit
1
$0.00i
Total Deposits:
ACCOUNTING_
$160.00
$1,218.32001-41000-3572
$330.00
626-416-223-102
$0.00
001-441-000-100
$1,548.32
-
Fees/Council Date reviewed/confirmed
Note:__ - -
with: Date:
.