Portuguese Bend Cooperative Nursery School (1987) ?i r
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``� I PAr L T OF LEISURE S'"?!i:VIe
PIrtTEST FOR USE XIITYY R F WILT TI FS
Complete all questions below. Attach alcittionalam9es if nncensary.
•r......+r'1. Area requested ed LLt�� eL ww.rl ar+..+►c...L....) Room FIo. C,45,..5
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„K-:-.Z-. Date and hours requested: From: get,rn Vtt' r�d1 To: fl2Oti VzrcS........._.
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3. Type of activity Of er Ch - - &itT, ±±ci/3e11-.7
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4. Anticipated attendance: Youth m ,x,�,Ins .Mults r_+ Pry
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5. Name of applicant /; ,4"�hf!e--11_21±C5.-.7"cc.),9-1Home Phone e 3 i-'LC Ls-
15'is1°1etis (1"-c.4-4/1- ,.
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6. Address boa 3 flopiltbs.......,Delke, City e,p v. Zip 23 73.a__.
7. Na r~:e of or ani zat ion /fes q�.�P_ "-C liefir{ l , c« c..:2Z ✓e �y//1b.)- �- . ./ Sr1/1...)1
.I �1/ :,.w+J'.� w-..._+..r.��•rrll�r�w w�r.�::. �w.�+wrrw�+w.�... :....r�r.a�.-.G.rry � �.6��. y�
8. Your position in the or anixation re',,C!dr!elt
Thez �
9. majority of members of thin organization �-e�.�ide +n the City of :ffi? P/ �.
(a roster may be requested. )
INDMMNITY STATTrENT
I hereby certify that I will abide by all rules and regulations of the City cf
Rancho Palos Verdes and will enforce such rubs thilong prtici?ants la 1L,1,
organization. ?.s a duly authorized r^p'-ezentativn o7.. the rlr• -�sting or�j:..r.izat4on,
end on behalf of the rsqueatinv organiz icy, I t ra to :t-- e, k cei, aizd hear
harmless the City of Rancho Palos 1;,:rdil and all its officers and b jilts from
all damages, costs or expenses in law or equity (including coats of suit and
expenses for legal services) that ri, y arte2 or 11-a Let up bccaus: of d rna 1e to
property or death or injury to p rE,3ne recfAvd or suffered in connect on with
the event described above which may be ovcl. sion::d by any nesligenre on the phrt
of the requesting organization cr any of its agn :s or employees, or any act or
omission ssio:t to act on the part of said organization, its a :l�.s or employi:e s wl}i ch
result in a di:ngereous condition of property un requestt;d City facility.
Signatures- �/�� _, _701(_-. AD Darei LJ27'n+- .x•
t 4 i 440,40-C., ..e.,,,t-e.-e6
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ewe.._..-r�rY•+�w�a.......�'`• ������
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s TO BE COMPLETRD BY TF Z rRrAhTMI7NT C7 T.7I7R1 LIRE..:.-RV C:;S
Is this event jointly sponsored by Leisure Services? L Yea 17 No
Is the requested facility avail'Me? :' Yes /,' . fto
Utilities available: j Water CI Electricity 1„7 Sanitation
iry Approved Disapproved Date notice mailed �..
Use Fee x u:�. :s hourspaid
$ $ Date
alcohol Beverage Fee $ Late paid
Kitchen Use . .4 Date paid
Dance Floor Rental AL_ D?te paid
- __ Staff Fee $ D t� p*.i d
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T:TAL S Lath paid
' DEPOSIT 1._ Date paid _.
Cleaning/security deposit (refundable if $175.00 Date paid ____
conditions met)
Balance Due ,$ , on - $ Date paid
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This permit is applicable only to the activityspecified pe above and may not be
construed as exclusive use of the area. The City reserves the right
functions9 t to cancel
this permit where City conflict.ct. Permission for any other event must
be requested in writing from the Director of Leisure Services.
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. . AUTHORISING 131 GNATURE DATE
COMMITS:
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