SR 05:094 - Laserfiche WebLink

Hold Harmless and Compliance Agreement I certify that the above information is accurate. I certify that [ have read the Rules and Regulations pertaining to facility use and agree to comply with the Rules and Regulations. I further agree to be personally responsible for informing those using the facility as scheduled in the Agreement of the rules and regulations of the City. I, or organization, through me, agrees to be responsible for any damage sustained by the facility, equipment, or furniture during use of the facility and further agree to release and hold harmless the City of Pleasanton form any and all liability for damage or injury to person or property of the undersigned due to use of said facility. Evidence of this Hold Harmless and Compliance Agreement shall be provided through a Certificate of Liability Insurance from any insurance carrier or, if available, through special facilities insurance purchased through the City of Pleasanton. Signature of Renter/Representative Organization Date Facility Rental Fees (to be completed by Office only) Facility Booking Code Number Date Priority: __Cosponsored __Resident __Nonresident __Commercial Month/Date/Year Authorized Signature Approved/Disapproved Rental Fee Basic Fee $ Extra Hours: __ Number of Hours x $ per hour = $ TotalRentalFee: $ Amount Paid Account # Date/Staff Balance Due Reservation Deposit* $ Damage Deposit** $ Insurance Fee $ Extra Fees: $ $ $ $ Rental Fee Balance $ Final Payment is due on, and all other required documentation: Month/Day/Year *Required at time of reservation. This is deducted from the Rental Fee Balance. **If all rules and regulations are followed, this will be refunded to you within three (3) weeks of event. Other Required Permits/Certificates Received Certificate of Insurance Business License Information Fire Permit __ Alcohol Beverage Control Board License Room Set Up Plan