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?i r <br /> . 1r <br /> v.f'ti''• 4. <br /> T <br /> IIP <br /> 6,. t: �:L- E . CITY o r.... cao nips ips irm rs <br /> ``� I PAr L T OF LEISURE S'"?!i:VIe <br /> PIrtTEST FOR USE XIITYY R F WILT TI FS <br /> Complete all questions below. Attach alcittionalam9es if nncensary. <br /> •r......+r'1. Area requested ed LLt�� eL ww.rl ar+..+►c...L....) Room FIo. C,45,..5 <br /> •- <br /> (....e.cm_____ <br /> / ♦ S�r2 <br /> „K-:-.Z-. Date and hours requested: From: get,rn Vtt' r�d1 To: fl2Oti VzrcS........._. <br /> f,:. ��.,e, <br /> .pi. <br /> 3. Type of activity Of er Ch - - &itT, ±±ci/3e11-.7 <br /> ----) <br /> 4. Anticipated attendance: Youth m ,x,�,Ins .Mults r_+ Pry <br /> . �• w•-.rr.r�r -r.rr•a _ <br /> 5. Name of applicant /; ,4"�hf!e--11_21±C5.-.7"cc.),9-1Home Phone e 3 i-'LC Ls- <br /> 15'is1°1etis (1"-c.4-4/1- ,. <br /> . <br /> 6. Address boa 3 flopiltbs.......,Delke, City e,p v. Zip 23 73.a__. <br /> 7. Na r~:e of or ani zat ion /fes q�.�P_ "-C liefir{ l , c« c..:2Z ✓e �y//1b.)- �- . ./ Sr1/1...)1 <br /> .I �1/ :,.w+J'.� w-..._+..r.��•rrll�r�w w�r.�::. �w.�+wrrw�+w.�... :....r�r.a�.-.G.rry � �.6��. y� <br /> 8. Your position in the or anixation re',,C!dr!elt <br /> Thez � <br /> 9. majority of members of thin organization �-e�.�ide +n the City of :ffi? P/ �. <br /> (a roster may be requested. ) <br /> INDMMNITY STATTrENT <br /> I hereby certify that I will abide by all rules and regulations of the City cf <br /> Rancho Palos Verdes and will enforce such rubs thilong prtici?ants la 1L,1, <br /> organization. ?.s a duly authorized r^p'-ezentativn o7.. the rlr• -�sting or�j:..r.izat4on, <br /> end on behalf of the rsqueatinv organiz icy, I t ra to :t-- e, k cei, aizd hear <br /> harmless the City of Rancho Palos 1;,:rdil and all its officers and b jilts from <br /> all damages, costs or expenses in law or equity (including coats of suit and <br /> expenses for legal services) that ri, y arte2 or 11-a Let up bccaus: of d rna 1e to <br /> property or death or injury to p rE,3ne recfAvd or suffered in connect on with <br /> the event described above which may be ovcl. sion::d by any nesligenre on the phrt <br /> of the requesting organization cr any of its agn :s or employees, or any act or <br /> omission ssio:t to act on the part of said organization, its a :l�.s or employi:e s wl}i ch <br /> result in a di:ngereous condition of property un requestt;d City facility. <br /> Signatures- �/�� _, _701(_-. AD Darei LJ27'n+- .x• <br /> t 4 i 440,40-C., ..e.,,,t-e.-e6 <br /> //^/\ 1C <br /> \./ 04<.. ) CA...e.. ._0....,:re6,,f <br /> !_ .+.•rte.n <br /> ewe.._..-r�rY•+�w�a.......�'`• ������ <br /> 1 ,........ ? <br /> s TO BE COMPLETRD BY TF Z rRrAhTMI7NT C7 T.7I7R1 LIRE..:.-RV C:;S <br /> Is this event jointly sponsored by Leisure Services? L Yea 17 No <br /> Is the requested facility avail'Me? :' Yes /,' . fto <br /> Utilities available: j Water CI Electricity 1„7 Sanitation <br /> iry Approved Disapproved Date notice mailed �.. <br /> Use Fee x u:�. :s hourspaid <br /> $ $ Date <br /> alcohol Beverage Fee $ Late paid <br /> Kitchen Use . .4 Date paid <br /> Dance Floor Rental AL_ D?te paid <br /> - __ Staff Fee $ D t� p*.i d <br /> • <br /> T:TAL S Lath paid <br /> ' DEPOSIT 1._ Date paid _. <br /> Cleaning/security deposit (refundable if $175.00 Date paid ____ <br /> conditions met) <br /> Balance Due ,$ , on - $ Date paid <br />