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CITY OF COLTON NEIGHBORHOOD SERVICE DIVISION FACILITY USE APPLICATION AND AGREEMENT (909)370-6153 REQUEST FOR USE OF FI (DATES) S - Z ZS FACILITIES AND EQUIPMENT REQUESTED ❑ Main Room O Tables # ❑ Dance Room U Chairs # ❑ Activity Room Cl Pool ❑ Meeting Room NOTE: PLEASE SUBMIT DIAGRAM S OF SET-UP REQUESTED AT ❑ Kitchen LEAST 48 HOURS PRIOR TO ❑ Game Room SCHEDULED USE. ❑ Baseball Diamond ❑ Field Lights - Time O Snack Bar - Time _ Fjeming Park (Must be approved by Council) Stage TIME OF USE (I I4de set -u / clean-up time) FROM - Uf1-hi TO 8"- X7 12-8 Purpose of Activity,9 11�P, N4 nce &r &2 .� Expected Attendance: Adults t� 0 Youths �S # of Colton Residents O20 / Is Activity Open to the Public: Yes No 1 Will Admission Be Charged: Yes No Will Donations Be Accepted: Yes No If yes, what will the proceeds be used for? DEPT. USE ONLY Received. Initials Date / Time Processed Date / Initial Calendar Date / Initial We hereby certify that we shall be personally responsible, on behalf of our organization for any damage or unnecessary abuse of buildings, grounds or equipment throughout the use of said premises by our organization. WE AGREE TO ABIDE BY AND ENFORCE THE RULES AND REGULATIONS OF THE CITY OF COLTON AND CERTIFY THAT WE HAVE READ THE RULES AND REGULATIONS ON THE BACK OF THIS APPLICATION. We also received a copy of the Independent Contract Agreement. Yes No Ins. Initials - H. H. A. Will process IN.Proc. Name of Organization Name (please print) Signature Contact Person @ Event 'JifulFERL kO N Title alfto t E T Eft "'E -Q Address 2 u l t Mac; r �� City, Zip Code C Phone (daytime 9 C) C -t l t R 2 Q" b9. 12 Phone (eveningiol O 41 6:1 5 -X24 S Date of application '7-2 Z 19 17117 ' 1 FOR DEPARTMENT USE ONLY Application For Facility Use Ic• Charges mother Charges Amount Fleming Park: Council Approved Denied DepositVCR / TV Facility Approved Denied BallfieldPool By FacilityKitchen Name of Customer Called Cost of StaffGym By Whom Date Cost of LightsInsurance Approval Is Subject To Conditions Listed On Back PA System Staff Assigned Stage Other Date Staff Assigned Time Staff Assigned Assigned by (Supervisor) Actual Expense (both columns) = Keys picked up: Amount Charged to Applicant = Staff Member Date Paid , 19 _ Initials Remarks E) 5[ n Date Proc'd 1 ' , 19 _ Initials r w� - N� CSS {� +D c � Fax Notification: Public Works: Risk (Ins.) PD Fire Elec. Date Date Date Date Date Date Rcvd Apprvl Inst. Public Works: Risk (Ins.) PD Fire Elec. Date Date Date Date Date Date sf i�c cry S w /!/ al of b e to c1 ter- a n /) 7 '�/` LCyJ 12/01/98 Facility Use App.