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t iuMFh SERVIIF <br />CITY OF COLTON <br />NbIOHDORHOOD SERVICE DIVISION <br />PACIIAI Y USE APPLICATION AND AGREEMENT <br />(909)370-6153 <br />REQUEST FOR USE OF J \ <br />(DATES) 10/23/99 <br />FACILITIES AND EQUIPMENT EGQUKSTED <br />D Main Room O Tables A <br />u Dw=Room O Chairs !< <br />0 Activity ROOM ° pool <br />U hltai�gftoom NOS- PLIASIESUSIIr MAGRAM <br />Of9E[.L'PMITMAT <br />O Kitchen LRAbIw 1ARMas PMR TO <br />0 Game Roan 9Co1TInEDUSL <br />Baseball Diamond <br />0 Ficld Liahtc - Time <br />R Snack Dar - nate <br />UK Fleming Park (Must be approved by Council) <br />III Stage <br />I'1IME OF USS <br />02* aa -up; cica s -up time) <br />:(& <br />FROM R7 <br />TO 07:00 PM <br />Pwposc of Activ ty H=CAL W GVM <br />Expected Atteaduaw: Adults 175 <br />Youths 5 <br />9ofColton Residents 210 <br />Is Activity Open to the PObU . Yes ,j_ No <br />WiU Admission Be Charged: Yes _ No X <br />Wdl DOMMIS PJC Accepted. Yes X No _ <br />If yes, what will the proceeds be used fort PANPROM M. <br />WRLM LTR <br />M <br />AMHOUM For FROM UAC Is <br />Ffemipg Park: C.antcil ADDrosw! _ _ Denied _ _ <br />Facility Approved Denied <br />By <br />Name of Customer Called <br />By Whom- Date <br />Approval Is Subject To Conditions Listed On Back <br />Staff Asdgatd <br />Date Staff Assigned Time StafAssigned <br />Assigned by (Supervisor) <br />E Keys p icked up: <br />qI stair asember <br />I Remmka: <br />001 <br />DEPT. USE ONLY <br />Received. <br />Initials <br />txre f Time <br />Procenead <br />Date J IRIEW <br />Calendar <br />uate , smuat <br />We hereby eestify dud we shall be penomily responsible, on <br />behalf of our argatuzauiat fa any daatsge or uwwmsary abuse <br />of buildings, )pounds or ecluipmestl throughout the rase of aid <br />)xemlm by our organintion. <br />WEA69FE TO ABIDE BY AND BFURCE Tff RUI,@S <br />AND REGULATIONS OF THE CITY OF COLTON AND <br />CERTIFY THAT WE HAVE READ THE RULES AND <br />REGULATIONS ON THE BACK OF THIS APPLICATION. <br />We oleo mceieed a copy of'the Indepeodesu Construct <br />Agneemptt_ Yee — — No <br />Ins. X <br />Initials-R.R.A. Wuirycessimpm. <br />Netneoforgenisdim LIG11'.M US'ENOW <br />HOLY HAND <br />Name (please print) <br />Signdure -0-j <br />I- <br />Comect Pcnon !$ Event, I.rr.r.rv. ALd:1C1 Al�lEt <br />-lisle PMIDEW <br />Address 495 N IA CADWA <br />City, Zip Code COLTON 92324 <br />Phone (daytime) 909-825-2416 <br />Phase (eve -int) 909-787-7858 <br />Date of application 9/2B 11999 <br />Dais Proe'd ,19_ Initials <br />Fax Nooboadon: Public Works: Risk (hu.) PD piss Flee. <br />Rete Iwc Dee 5w Date Iavte <br />Revd Apptvl Inst. Public WOsks: Risk (Ins.) PD Pin Gioe. <br />Done Tire two Dw nae —fAu <br />W" <br />FdalitY UseApp. <br />