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CITY OF COLTON <br />NE'GHBOMOOD SERVICE DIVISION <br />FACILITY USE APPLICATION AND AGREEMENT <br />(909) 370-6153 <br />REQUESTFORUSEOF <br />(DATES) <br />A,-, <JL0. a- AD- "'30 <br />FACILITIES AND EQUIPMENT REQUESTED <br />13 Main Room U Tables # <br />• Dance Room L1 Chairs # <br />• Activity Room Q Pool <br />• Meeting Room NOTE: PLEASE SUBMIT DIAGRAM <br />OF SET-UP REQUESTED AT <br />13 Kitchen LEAST 49 HOURS PRIOR TO <br />D Game Room SCHEDULED USE. <br />13 Baseball Diamond <br />Q Field Lights — Time <br />0 Snack Bar — Time <br />X Fleming Park (Must be approved by Council) <br />1W Stage TIME OF USE <br />(include set-up / clean-up time) <br />FROM <br />TO <br />Purpose of Activity 5a� s <br />Expected Attendance: Adults S'10 0 <br />Youths <br /># of Colton Residents <br />Is Activity Open to the Public: Yes v" No <br />Will Admission Be Charged: Yes No Vol <br />Will Donations Be Accepted: Yes No <br />If yes, what will the proceeds be used for? <br />DEPT. USE ONLY <br />Received. 91+— <br />Date/ Time 5, Initials <br />4-qq II& <br />Processed <br />Date / Initial <br />Calendar <br />Date / Initial <br />We hereby certify that we shall be personally responsible, on <br />behalf of ourOrganization for any damage or unnecessary abuse <br />of buildings, grounds or equipment throughout the use of said <br />premises by our organization. <br />WE AGREE TO ABIDE By AND ENFORCE THE RULES <br />AND REGULATIONS OF THE CITY OF COLTON AND <br />CERTIFY THAT WE HAVE READ THE RULES AND <br />REGULATIONS ON THE BACK OF TIHS APPLICATION. <br />We also received a copy of the Independent Contract <br />Agreement. Yes ---X— No <br />Ins. <br />------ initials - �HH. A. Will process Ins.Proc. <br />Name of Organization <br />Name (please print) <br />Signature I <br />Contact Person @ Event (�tvt <br />Title " i <br />Address <br />City, Zip Code <br />Phone (daytime) <br />Phone (evening) <br />Date of application 6- � --qlg_, 19 <br />FOR DEPARTMENT USE ONLY <br />Annlionfj— P— P-;1,+— TT-- T­ <br />Flen;ingPark: Council Approved_ Denied <br />Facility Approved Denied <br />By <br />Name of Customer Called <br />By Whom ---Ba�te <br />Approval Is Subject To Conditions Listed Ci� —Back <br />Staff Assigned <br />Date Staff Assigned Time Staff Assigned <br />Xssigned by (Supervisor) <br />Keys picked up: <br />staff <br />Remarks: <br />Date Proc'd 19 _ Initials <br />TeX ""* -'D&*.eA3/10 <br />Fax Notification:_ Public Works: /Risk (Ins.)_., pD <br />Date Date . -- Fire Elec. _,e <br />Rcvd Apprvl Inst. - — Public Works: . Risk (Ins.) Date PD Date Fire Date Date <br />Date —Wte Elec. <br />Date Date Date Date <br />12/01/98 <br />Facility Use App. <br />