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CITY OF COLTON <br />NEIGHBORHOOD SERVICE DIVISION <br />FACILITY USE APPLICATION AND .AGREEMENT <br />1909)430-3572 <br />6 U <br />REQUEST FOR USE OF <br />(DATES)-- <br />FACILITIES A <br />❑ Main Room p Tables # <br />Li <br />Dance Room ❑ Chairs # <br />.Activity Room ❑ Pool <br />❑ Meeting Room NOTE: PLEASE SUBMIT DIAGRAM <br />❑ Kitchen OF SET-UP REQUESTEDAT <br />LEAST 48 HOURS PRIOR TO <br />Game Room SCHEDULED USE. <br />❑ Baseball Diamond <br />❑ Field Lights - Time <br />❑ Snack Bar -Time <br />IC Fleming Park (Must be approved by Council) <br />,,inQ Stage <br />TIME OF USE <br />(include set-up / clean-up time) <br />FROM 1 : Z�J- /f,/ _ <br />TO ,o <br />3urpose of Activity <br />Expected Attendance: Adults A <br />Youths / <br /># of Colton Residents Z,2-, <br />s Activity Open to the Public: YeNo <br />Vill Admission Be Charged: Yes Ng%C <br />Aiill Donations Be Accepted: Yes NO <br />f yes, what will the proceeds be used for? <br />/)C <br />FOR <br />.Application For Facility Use Is: <br />Fleming Park- Council Approved Denied <br />Facility Approved Denied <br />By <br />NameofC er lied <br />By Whom Dat <br />lApproval Is Subject To Conditions Listed On k <br />Staff Assigned <br />Date Staff Assigned Time Staff Assigned <br />}� Assigned by (Supervisor) <br />1 Keys picke up: <br />St e r tom, <br />VGr I. r JG V - Ni- r <br />Date! Initial <br />Date ! Initial <br />reby cert[ tat we s a e persona y response e, on <br />of our organization for any damage or unnecessary abuse of <br />igs, grounds or equipment throughout the use of said <br />es by our organization. <br />AGRFF, TO ABIDE BY AND ENFORCE THE RULES AND <br />3ULATIONS OF THE CITY OF COLTON AND CERTIFY <br />AT WE HAVE READ THE RULES AND REGULATIONS <br />THE BACK OF THIS APPLICATION. <br />also received a copy of the Independent Contract Agreement. <br />� No <br />ddr <br />Initials - H H A Will process Ins Proc <br />of Organization L idit siq <br />e (daytime) D 91 <br />e (evening) <br />of application /f V 19 %P. <br />USE ONLY <br />11 <br />Charges Amount <br />Charges Amount <br />Deposit <br />a to <br />o0 <br />act tty <br />Kitchen <br />ost o to zGym <br />Cost of Lights <br />nsurance <br />PA System <br />Other <br />tage <br />ter <br />Actual Expense (both columns) <br />= <br />Amount Charged to Applicant <br />= <br />fgmarks: v ate at Initials <br />tl� ( (J Date Proc'd , 19 Initials <br />Fax otifc 'on: Public Works: — Risk (Ins.) PD`-_ Fire Elec. <br />Date Dale Date Date Date Date <br />Rcvd Apprvl Inst. Public Works:!_ Risk (Ins-) PD Fire Elec. _ <br />Date Date Date Date Date Date <br />OR/03/99 <br />Facility Ilse App <br />