Fillable City Use Govt Agency Private Commercial Non-Profit (Lake Havasu City)

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City Use Govt Agency Private Commercial Non-Profit (Lake Havasu City)

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City Use Govt Agency Private Commercial Non-Profit
Estimated number of attendees:
Will you implement a charge for the event?
Will food be served?
Relics & Rods Hall Rental Charges Worksheet is needed for events offering alcohol
Will you have merchandise for sale?
If yes, do you have a Lake Havasu City business license?
Will your event have vendors? Number of anticipated vendors
Will vendors provide food/beverages? Free Catered Served
Do vendors have all permits/licenses with Mohave County Environmental Health Dept?
Do vendors have a Lake Havasu City Temporary Business License?
Please check all applicable areas of use for your event:
Relics & Rods Hall Room 152 Room 153/154
1/2 hall (front/stage)
Room 155/156 Jane Camlin
1/2 hall (back/kitchen) Parking Lot Area
Other
Kitchen Area
CA 1.10.18
Address:
(Group Name)
Approved by:
Date:
FOR OFFICE USE ONLY
Total Due:
Cash/Check/Charge:
Applicant's Signature:
No
Description of Use:
Adults
Phone:
Cell:
Email:
Please give a brief description to any "Yes" answers above:
Yes
Phone: (928) 453 - 8686 FAX : (928) 453 - 1133
FACILITY USE PERMIT
Lake Havasu City Aquatic/Recreation Division
100 Park Avenue • Lake Havasu City, AZ 86403
DATE RECEIVED:
Applicant:
Contact Name:
City, State, Zip:
Yes
No
Will you require use of sound equipment?
Date:
No
No
Yes
All applicants, vendors, and customers must abide by all local, state, and federal laws. This permit may be revoked by Lake Havasu City at any time.
To the fullest extent permitted by law, Applilcant agrees to indemnify, defend, save, and hold harmless the City, its departments, agencies, boards, commissions,
officers, officials, agents, volunteers, and employees (“Indemnitee”) for, from, and against any and all claims, actions, liabilities, damages, costs, losses, or
expenses (including, but not limited to, court costs, attorneys’ fees, and costs of claim processing, investigation and litigation) to which any Indemnitee may
become subject, under any theory of liability (“Claims”) to the extent that Claims are caused by the negligent acts, recklessness, or intentional misconduct of the
Applicant, its officers, employees, agents, volunteers, customers, or any tier of subcontractor in connection with Applicant's work or services in the performance
of this Agreement. This Indemnity includes any claim or amount arising out of or recovered under the Workers’ Compensation law or arising out of the failure of
Service Provider to conform to any federal, state, or local law, statute, ordinance, rule, regulation, or court decree. Service Provider agrees it will be responsible
for primary loss investigation, defense, and judgement costs where this indemnification is applicable.
Yes
Yes
Yes
No
No
No
A completed vendor list must be submitted to the Aquatic/Recreation Office at least 72 hours before the use of a facility, which must include the following
information for each vendor: Company Name, Doing Business As (DBA), Operator/Contact Name, Address, Phone Number, Owner's Name, Type of Business,
Lake Havasu City Business License Number (Annual or Temporary), and Arizona State Transaction Privileged Number (TPT). Failure to provide a vendor list
may result in the denial of a Facility Use Permit.
Date(s) of Use:
Youth
Does event require bar set up?
Start/End Time:
Yes
No
Yes
No
Sold
Yes
Yes
No
Room Set-up: Please indicate how you would like to have the room set-up.
Horseshoe (U) Set-up with tables: How many people
Classroom Style with tables and chairs: How many people
Theatre Style (just chairs) : How many people
Head Table:
TV/VCR/DVD is available in all meeting rooms.
Please supply any additional information, requests, or instructions:
Room 152
Room 153/154
Room 155/156
Jane Camlin
R&R Hall & Rooms
R&R Full Hall
R&R Half Hall
Kitchen
Parking Lot
TOTAL DUE:
$300 REFUNDABLE CLEANING DEPOSIT REQUIRED FOR ALL LARGE EVENTS IN RELICS & RODS HALL
If offering alcohol, complete and submit the Relics & Rods Hall Rental Charges Worksheet.
TOTAL
TOTAL
TOTAL
$62 /
$125
4hr /
8hr
$29 /
$57
$16 /
$32
$31 /
$62
Applicant shall purchase and maintain General Liability Insurance in the minimum amount of $1,000,000 for each occurrence/$2,000,000
aggregate. The policy must provide coverage for bodily/personal injury, property damage, and broad form contractual liability. The policy must be
endorsed to include Lake Havasu City, Arizona, its departments, agencies, boards, commissions, officers, officials, agents, volunteers,
employees, or contractors as named additional insureds with respect to claims arising out of the use of the facilities and contain a waiver of
subrogation against the City. The City must be notified within ten business days of policy suspension, cancellation, and reduction in coverage or
limits. Insurance coverage must be provided by an insurance company admitted to do business in Arizona and rated A-VII or better. Attach a
copy of the General Liability Insurance Certificate to this application.
4hr /
8hr
4hr /
8hr
$75 /
$150
TOTAL
Account # for City Use Only
$155 /
$310
TOTAL
TOTAL
TOTAL
$50 /
$97
$21 /
$42
TOTAL
$187 /
$373
TOTAL
$93 /
$186
$140 /
$280
$78 /
$155
$186 /
$373
$224 /
$446
$124 /
$248
$233 /
$465
$310 /
$621
$372 /
$745
$62 /
$124
$117 /
$233
$156 /
$310
$17 /
$34
$31 /
$63
$41 /
$84
$75 /
$149
$349 /
$699
$25 /
$50
$186 /
$373
$47 /
$94
$233 /
$466
$559 /
$1,116
$466 /
$932
$75 /
$150
$31 /
$62
$62 /
$125
$43 /
$86
$25 /
$50
4hr /
8hr
4hr / 8hr
$57 /
$115
$69 /
$137
$12 /
$25
$23 /
$47
$31 /
$63
$37 /
$73
Yes
No
INSURANCE REQUIREMENTS
FOR OFFICE USE ONLY
Non-
Profit
City
Use
Govt
Agency
Private
Use
Comm-
ercial
$47 /
$94
$23 /
$46
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City Use Govt Agency Private Commercial Non-Profit (Lake Havasu City)

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Completed 3 August 2020

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