Fillable Bellevue School District Building Use Application

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Bellevue School District Building Use Application

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Application No.
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 
BUILDING USE APPLICATION
5
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Applicant Information
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ZIP Code
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School Information
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
revised 12/2018
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Payment Information
 



Requirements

A $20 non-refundable processing fee must accompany this application. For information on the Building Use Fee
Schedule, please go to or the Facility Scheduler or the Facilities
Department has copies of the current fee schedule. Checks shall be made payable to: Bellevue School District No.
405. Please indicate the school and application number on the check. 
 



with Bellevue School District No. 405, its directors, oicials, employees, and
volunteers are to be covered and named as an additional insured, on the Commercial General Liability policy with
respect to liability arising out of the operations of the insured. The policy must have



provisions
and be endorsed. The address to be noted on the certificate of insurance should be 12111 NE 1
st
St., Bellevue,
98005.
The Certificate of Insurance should acknowledge the hold harmless agreement stated below and the liability insurance
requirement shall be provided to the District one week prior to the scheduled use of the field. User(s) shall agree to
defend, protect, and indemnify for costs, legal, and any and all other expenses or damages and to hold harmless the
District, its oicers, employees, agents, and directors, from any and all claims, liabilities, or suits arising directly or
indirectly out of user's use of the synthetic fields, and related or adjacent facilities. User(s) shall obtain liability
insurance for no less than $1,000,000 combined single limit bodily injury and property damage. 


Building use cancellations must be in writing seventy-two (72) hours in advance of the scheduled use to
be eligible for a refund or fee adjustment.

 
A reement and Si nature

 
 

Signature:
Date:
Signature:
Date:
School (insures custodial staing arrangements will be made if required)
Signature:
Date:
Facility Department Approval

revised 12/2018
2
AGREEMENT
  
 


 



NOTICE TO USER OF SCHOOL FACILITIES: 
  
Certificate of Insurance 
RULES AND REGULATIONS GOVERNING AFTER-SCHOOL USE OF BUILDING AND FACILITIES 
 
  
 

  
   

 

  
 

    
  

  
 
 
    
 


 
      

 
    
  
  
revised 12/2018 3
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Bellevue School District Building Use Application

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Completed 2 October 2019

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