SYRACUSE CITY SCHOOL DISTRICT
Department of Facilities Management
Sharon L. Contreras, Ph.D.
725 Harrison St• Syracuse, NY 13210
Phone 315•435•4083• Fax 315•425•5225
E-Mail: KPark@SCSD.US
Superintendent of Schools
APPLICATION FOR BUILDING USE
This is a request for a building permit only, a computer generated permit will be sent to you
when all signatures and insurance are in place. Please be aware that there may be fees
associated with this request for use.
TO:
Kris Park, Building Permits - Facilities Management Office
FROM:
_____________________________________ PHONE # ________________
DATE:
_____________________________
Name of person in charge of event: _______________________________________
Organization name: ____________________________________________________
Organization address: __________________________________________________
_______________________________________________________
On site contact person: ____________________________________________
Event name: ______________________ Number of participants/attendees: ________
School/Building name: ______________________________________
Day(s) of week: _______________________________________________________
Date(s): _____________________________________________________________
Times requested (including set up and clean up): ___________________________
Nature of event: _______________________________________________________
Rooms: _________________________________________________________
ADDITIONAL INFORMATION
Furniture/Equipment Required
Chairs
How many?_________
Tables
How many?_________
Doors
Opened at what locations? _______________________________
Rest rooms
Which ones? ___________________________________________
RENTER’S RESPONSIBILITY
Supervision of all participants
REQUIRED PRIOR TO PERMIT BEING FINALIZED: ALL outside groups must provide
a copy of own insurance equal to $1,000,000.00 of coverage.
(naming Syracuse City School District as an additional insured)
Custodian’s comments: ______________________________________________________
___________________________________________________________________________
___________________________________________________________________________
For Facilities Mgmt. Use Only
Custodian’s signature:
Approved: ________
__________________________________
Disapproved:________
No. of Men: ________
Principal’s (or designee) signature:
Charge: ________
__________________________________
By:_______________
No Charge: ________
Date:______________