1999 AGN MAR 16 I16 - Laserfiche WebLink

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DEPT. USE ONLY CITY OF COLTON Received. NEIGHBORHOOD SERVICE DIVISION Initials FACILITY USE APPLICATION AND AGREEMENT Date /Time 09) 370-6153 Processed REQUEST FOR USE OF S 7"t.tie-b Date / Initial (DATES) Calendar -ei1Y1 1 Date / Initial FACILITIES AND EQUIPMENT REQUESTED ❑ Main Room ❑ Tables # ❑ Dance Room ❑ Chairs # O Activity Room ❑ Pool ❑ Meeting Room NOTE: PLEASE SUBMIT DIAGRAM OF SET-UP REQUESTED AT ❑ Kitchen LEAST 48 HOURS PRIOR TO ❑ Game Room SCHEDULED USE. ❑ Baseball Diamond ❑ Field Lights – Time ❑ Snack Bar – Time l"Fleming Park (Must be approved by Council) �l Stage TIME OF USE (include set-up / clean-up time) FROM —�--. m TO Purpose of Activity 16) Elb Expected Attendance: Adults Youths 10 # of Colton Residents Is Activity Open to the Public: Yes No Will Admission Be Charged: Yes No Will Donations Be Accepted: Yes No If yes, what will the proceeds be used for? 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 Ins.Proc. Name of Organization Name (please ' t) Q Signature Contact Person v t o a b 0 Title 11 Address City, Zip Code Phone (daytime) _ -0 1 SO Phone (evening) &:2r— 3 71 Date of application , 19 FOR DEPARTMENT USE ONLY Application For Facility Use Is - Fleming Park: Council approved Denied Facility Approved Denied By Name of Customer Called By Whom Date Approval Is Subject To Conditions Listed On Back Staff Assigned Date Staff Assigned Time Staff Assigned A.ssigned by (Supervisor) Keys picked up: Staff Member Remarks: Charges Amount I Charges I Amount Cost of Staff Gym Cost of Lights Insurance PA System Other Stage Other Actual Expense (both columns) = Amount Charged to Applicant = —a,� 1 aLLL , I initials Date Proc'd , 19 Initials Fax Notification: Public Works: Risk (Ins.) IPD Fire Elec. Date Date Date Date Date Date Rcvd Apprvl Inst. Public Works: Risk (Ins.) PD Fire Elm. Date Date Date Date Date Date 12/01/98 Facility Use App.