5/09/2019
FACILITY USE PERMIT City of Stayton
3
11 N. Third Ave.
Stayton, OR 97383
(503) 769-2919
Req
uest to Rent: Entire Community Center Community Center- South End (has kitchen)
Community Center- North End Jordan Bridge Concession Stand
*Pl
ease visit www.staytonoregon.gov
to review the City of Stayton’s “Facility Use Rules” document.*
Ap
plicant Name:_____________________________________ Stayton Resident: Yes No
Mailing Address:_______________________________ City:_____________________ State: ____ Zip:___________
Contact: (home)____________________ (cell)_______________________ (email) ___________________________
Date(s) Requested:___________________ Event Begin Time:___________ Event End Time:_____________________
(includes set-up & clean-up)
Type of Event:_________________________ Civic Private Commercial # of people to attend:_____
Will there be a band/DJ? Yes No Will there be food or beverages served? Yes No
Will there be alcohol? Yes No (If YES, please complete separate Application for Alcohol Use)
MATERIALS AND EQUIPMENT AVAILABLE FOR COMMUNITY CENTER USE: 19 6-Ft. Tables, 2 8-Ft. Tables, 135 Chairs, and a
Podium $100 Charge for use of the Tables & Chairs # of Tables
Requested:_______________________________
I hereby apply for a City of Stayton Facility Use Permit. I have read, understand and agree to comply with all rules and regulations set forth by the City of Stayton.
I further pledge that I am of legal age and will be responsible for the care of the facility during its use. Further, I will be responsible for the repair of damage to
equipment or the facility should any occur and for the replacement of any inventory or equipment lost or damaged during the use of the facility for the activity
for which I have accepted responsibility. I further understand that this permit is revocable at any time and that the permit is not transferable. I also understand
City rules and regulations are subject to change without notice.
I a
gree to indemnify and hold harmless the City of Stayton (“City”) from liability for any and all claims, causes, actions, loss, damage or expenses of any kind
whatsoever which may be asserted against the City and/or the Applicant or incurred by my agents, contractors, invitees or guests, including attorney’s fees and
costs, arising out of or resulting from the Applicant’s use of the City’s facility.
It is agreed that the Applicant shall abide by all federal, state and municipal laws, regulations and code, applying equal opportunity in all respects and prohibiting
discrimination of any kind.
______________________________________________________ ___________________________________________________
Authorized Signature of Applicant Date Approved by City of Stayton Date
Notice: Oregon law (ORS 105.682, et seq.) provides that the owner of land is not liable in contract or tort for injury, death or property damage that arises out of use of the land for
recreational purposes (known as “recreational use immunity”). That immunity from liability does not apply if the owner makes a charge for permission to use the land. This fee is only
for use of the assigned facility and/or park rental area and for use of the amenities in the designated facility or park rental area. Other uses of this park or any use of this property
outside the facility and/or designated park rental area are not subject to a charge and therefore, the City of Stayton is not liable for injuries, death, or property damage arising out of
such uses of the property for which no specific charge is assessed.
DO NOT WRITE BELOW THIS LINE: CITY USE ONLY
Community Center Hourly Rate: $ x hours = $
x 25% non-resident fee $
= $ Total Rental Fee
Jordan Bridge Rental Fee:
$100 (first 3 hours) + ($20 x hour(s)= $ Subtotal= $ x 25% non-resident fee $ = $ Total Rental Fee
Cleaning Fee: $___________ Table & Chair Rental $100 Yes No Total Cost:$_____________________
(Rental, Cleaning, Table/Chair Rental)
Pa
yment: $________ Date Paid:______________ Receipt No. _____________________ Initial: _________
Payment: $________ Date Paid:______________ Receipt No. _____________________ Initial: _________
click to sign
signature
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