BOROUGH OF PORT VUE APPLICATION FOR RENTAL OF THE PORT VUE COMMUNITY CENTER COMPLEX/INDOOR RECREATION FACILITY Name ofA Applicant/Borough Resident: Applicant Phone Number and Email Address: Address of Applicant: Applicant seeks to rent the Port Vue Community Center Complex/Indoor Recreation Facility for the following use: Applicant seeks to rent the Port Vue Community Center Complex/Indoor Recreation Facility for the above-described use during the following dates and times: Applicant expects (#) of people to be in attendance. Application is hereby made to rent the indoor recreation facility for the purpose and period described, above. If your dates, times, or proposed usage for the facility are unacceptable to the Borough, the Borough will contact you to deny this application. Date: Signature of Applicant SECURITY DEPOSIT PAID (AMOUNT) APPROVED: BOROUGH MANAGER RENTAL AND HOLD HARMLESS AGREEMENT THIS AGREEMENT is made and executed this day of 20 by and between the Borough of Port Vue, 1191 Romine Avenue, Port Vue, PA 15133 (hereinafter "Borough"), and (herinafter-Lesee"). WHEREAS, Lessee desires to rent from Borough the indoor recreation facility located at ADD ADDRESS OF FACILITY (hereinafter "Facility") for use of the Facility for a purpose permitted by the Borough. NOWTHEREFORE, thej parties hereto mutually agree as follows: ARTICLEI-RENTALAGREEMENT 1.1 Lessee will rent the Facility on (Date) from AM/PM to AM/PM (the "Rental Period") for the purpose of (Please add as short description ofyour intended use of thel Facility): 1.2 Lessee expects persons to be in attendance during thel Rental Period. 1.3 Lessor, upon a rental payment ofs plus a security deposit of$ agrees toj permit Lessee to. have exclusive use ofthe Facility during the Rental Period. 1.4 Lessee agrees that half of the total rental price and the security deposit are due at the time ofe executing this Rental and Hold Harmless Agreement. The remaining balance is dueon the day of thel Lessee's event. The security deposit is refundable within 2 weeks afterf final inspection, provided no damage is done to the Facility of any furniture, equipment, etc. located in thel Facility. ARICLEI-AGREENENTTOFOLLOW RULESFORTHE PREMISES 2.1 Port Vue hereby grants the Lessee the use oft the Facility; and 2.2 Lessee hereby agrees to follow all rules and regulations which have been adopted by the 2.3 Lessee hereby promises, covenants and agrees to maintain the Facility clean and free of Borough with regard to the use ofthe Facility; and debris; and 2.4 Lessee hereby agrees to perform, fully obey and comply with all ordinances, regulations and laws of all public authorities, whether federal, state or municipal, relating to the use, condition and occupation oft the Facility. ARTICLEII-INDEMNIFICATION ANDI HOLD HARMLESS! PROVISION 3.1 Lessee understands that by renting the Facility, Lessee is responsible for the safety of Lessee and all in attendance to the point of producing a safe event of activity during the length of the Rental Period. 3.2 Lessee hereby agrees to indemnify and hold the Borough harmless against any and all claims, causes of action, or liability, loss, damage or expense, including court costs and attorney's 's fees and attorney' s fees on appeal, for any and all claims fordamage to property, orir injury to, or death of persons arising from the rental and/or use ofthel Facility during the 3.3 Lessee hereby assumes all risk and responsibility of damages to the Facility and Borough property in and surrounding the Facility as it relates to Lessee's event and Lessee's use and/or misuse. Lessee agrees tohold the Borough harmless forany and all suits relating to Rental Period. the use ofBorough-owned facilities during the Rental Period. 3.3 Lessee agrees that Article III of this Rental and Hold Harmless Agreement shall be interpreted according to the law of the State of Pennsylvania. Lessee understands and agrees that Article. III shall bel binding on his/her/its heirs, assigns, and any entity acting on Lessee's behalf. IN WITNESS WHEREOF, and intending to be legally bound hereby, the parties hereto, forthemselves, their heirs and successors, haves set their hand this day of 20 2 ATTEST: Borough of Port Vue By: By: Title: WITNESS By: Lessee By: COMMONWEALTHOF PENNSYLVANIA ) SS: COUNTY OF ALLEGHENY On this the day of 2021, before me, a Notary Public, the undersigned officer or representative of Lessee, personally appeared whose names are subscribed to the within instrument and acknowledged that he/she executed the known to me (or satisfactorily proven) to be the persons same for thej purposes therein contained. IN WITNESS WHEREOF, ,I hereunto set my hand and official seal. Notary Public My commission expires: 3 Rental/Security Deposit Payment Information: Amount of Security Deposit: Initial Rental Payment Amount: Datel Due: Datel Paid: Remaining Rental. Amount: Date Due: Date Paid: Discount Amount (IfAny): Payment Type /Check Number: Borough Staff Signature: Lessee Contact Information: Name (and Main Contact Person): Address: Phone Numnber: Email Address: 4 COKD CERTIFICATE OF LIABILITY INSURANCE DATE (MMDDYYYY) 07:22/2021 THIS CERTIFICATE IS ISSUED AS AI MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY. AMEND, EXTEND OR ALTER THE COVERAGE. AFFORDED BY THE POLICIES 3ELOW. THIS CERTIFICATE OF INSURANCE DOES NOTO CONSTIUTEACONTRACTBETWEEN THE ISSUING NSURERS,AUTHORZED MPORTANT: Ifthe certificate holder is an ADDITIONAL INSURED, thep policylies) must have ADDITIONAL INSURED provisions or be endorsed. SUBROGATION IS WAIVED, subject to the terms and conditions oft the pollcy, certain policies may require an endorsement. Astatement on REPRESENTATIVE ORF PRODUCER, AND THE CERTIFICATE HOLDER. his certificate does not confer rights to the certificate holder in lieu ofs such endorsement/s). DDUCER ent NAME: CONACT Agent Contact PHONE AIC,NO, Ext: EMAIL, ADDRESS: INSURERA: Insurance Carrier INSURERB: INSURERC: INSURERD: INSURERE: INSURERF: FAX (AC.No): NSURERISIAFFORDING COVERAGE NAICE JRED Name ofF Party Usingt thei Facility VERAGES CERTIFICATE NUMBER: CL2172241372 REVISION NUMBER: TOALL THE TERMS. EACHOCCURRENCE DANAGET TORENTED PREMISES (Ea occurrence) MED EXP (Any one person) PERSONAL &ADVI INJURY GENERAL AGGREGATE PRODUCTS- COMPIOPAGG ÇOMBINED SINGLE LIMIT S (Eaa accidenti BODILYINJURY (Pern person! 5 BODILYI INJURY (Per accident) S (Peraccidenti PROPERTY DAMAGE S S EACH OCCURRENCE s AGGREGATE S PER OTH- STATUTE ER ELE EACHACCIDENT ELD DISEASE E EAEMPLOYEE S ELC DISEASE- -POLICYUIMIT S HISI IS TO CERTIFY THAT THE POLICIES OF INSURANCE! LISTEDE BELC oOW HAVE BEENI ISSUED TO1 THE! INSURED NAMEDI ABOVE XCLUSIONSAND CONDITIONS OF SUCHPOLICIES. LIMITS SHOWN MAYI HAVEE BEENF REDUCED BYF PAID CLAIMS. IDICATED. NOTWITHSTANOINGANY REQUIREMENT TERM OR CONDITION OFA ANY CONTRACT OR OTHER DOCUMENT WITH FOR THE POLICY PERIOD ERTIFICATE MAY BE ISSUED ORI MAY PERTAIN, THE INSURANCE AFFORDED: BYTHEF POLICIES DESCRIBEDI HEREIN IS SUBJECT RESPECT TO WHICHTHIS TYPEOFI INSURANCE COMMERCIAL GENERAL LIABILITY CLAIMS-MADE GENLAGGREGATEI LIMIT APPLIESPER POLICY PR OTHER: AUTOMOBLELIABITY ANYA AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY UMBRELLALIAB EXCESSLIAB DED RETENTIONS WORKERS COMPENSATION ANDE EMPLOYERSLABILITY ANYF PROPRIETORPARINEREXECUTIVE OFFIÇERMEMBERI EXCLUDED? (Mandatory inl NH) ilyes, descrice under DESCRIPTION OF OPERATIONS betow ADDLISUBRI INSD wVD Y POLICY NUMBER (MMDDYYYY POLICYEFF (MMIDDYYYY POLICYEXP 11/19/2020 11/19/2021 LIMITS 1.000.000 300.000 5.000 1,000,000 2,000,000 2,000,000 OCCUR LOC SCHEDULED AUTOS NON-OWNED AUTOS ONLY OCCUR CLAIMS-MADE YIN, NIA 3X3091921 RIPTION OF OPERATIONS: LOCATONS/VENCLES (ACORD1 101,Additional Remarks Schedule, may bea attachedi ifmore spacei is required) Vue Borough are named as additional insured regarding the activities oft the Named! Insured while using the Recreation/Sports Ise oft the Port Vue Borough Recreation'Sports Facility. ogationa applies inf favor of Port Vue! Borough Al Waiver Facility. of TIFICATE HOLDER CANCELLATION SHOULD/ ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVEREDI IN ACCORDANCE WITH THE POLICYI PROVISIONS. AUTHORIZED! REPRESENTATIVE Port Vue Borough 1191 Romine Avenue Port Vue RD: 25 (2016/03) PA 15133 01988-2015. 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