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NO REFUNDS! 41ty#:ce9 Permit # Statement of Intended Use of City Park _ City of Eugene Standard Park Use 0 Special Event Park Use Public Works EUGENE 1820 Roosevelt Blvd. Eugene, OR 97402 Approval of this form does not constitute an exclusive reservation of public open space. (541) 682 -4800 Make sure you have the PARK RULES pamphlet and GUIDELINES FOR EVENT PLANNERS. Return Completed form to Public Works, 1820 Roosevelt for review by City staff. STANDARD PARK USE permits must be submitted 10 working days in advance of event. SPECIAL EVENT PARK USE permit must be submitted 30 days in advance of event; SPECIAL EVENT PARK USE permits will not be accepted if submitted less than 15 working days prior to the event. Once approved, your copy may be picked up at 1820 Roosevelt Blvd., Monday- Friday, 8:00 a.m.-5:00 p.m. Please have your copy of this form with h you at your event, and remember to pick up your key prior to your event. NAME OF ACTIVITY CX'O� 1. P • ' N • • & • ` A (be p ci c ' •R ►� l � ear., 2. DATE - . _ u ', From 4 f� t to • • r 3. ESTIMATED • a CE 5 P a 4. WILL THIS EVENT BE FREE AND OPEN TO THE PUBLIC? YES o NO IS THIS EVENT BY INVITATION ONLY OR F • R ID IED I MBPRS .. o YES NO 5. SPONSORING ORG • IZATION •.�•�! ,: �I��. �� _ � , 1111. 1 Representativ e . • . - _ _ Phone IigreaK NUI VI. Address _ �e•'� ��S City/Zip . u _ . • w` S - -aaaY 6. TO BE COMPLETED BY APPLICANT J Yes I No I Check All Planned Activities Yes I No I Check All Planned Activities food will be servec3 \) participatory and/or registered sporting activity, such as bike race, road run and/or food will be sold walk alcohol will be served � admission fees (voluntary or mandatory) —.� will be collected alcohol will be sold ` �1 vehicle access to park is required items (crafts, art, etc.) Will be sold PLEASE LIST OTHER ACTIVITIES booths, canopies, stages, or other BELOW equipment will be erected amplified sound will be used for less than 2 hours amplified sound will be used for more than 2 hours 7./ SOUND PROVIDER IF REQUESTING APPROVAL OF AMPLIFIED SOUND: \ �' Amplified sound is limited to two hours for Standard Park Use permit. TIME From arn/pm to am/pm Sound Provider Phone TO BE COMPLETED BY OFFICE: Applicant must provide items required prior to DEPT USE Applicant must provide items required prior to DEPT USE approval approval temporary restaurant license rec'd Standard Park Permit fee AMT: /i rec'd( i (- y � To Certificate of General Liability Insurance rec'd Special Event Park Permit fee AMT: rec'd OLCC Permit rec'd facility user fee AMT: rec'd • Certificate of Liquor Liability Insurance rec'd V key and security deposits AMT: jW rec'dt ear 4412 0 site plan app'd Neighborhood Association approval rec'd route map for sporting activity app'd vehicle permit(s) fees AMT: rec'd entertainment schedule for use of amplified sound app'd equipment user agreement rec'd I certify that I am an authorized representative of the above organization, and that the above statements are true to the best of my knowledge. I have received a copy of PARK RULES and GUIDELINES FOR EVENT PLANNERS, and I and/or the organization I represent agree to be bound by all applicable regulations and policies. I and/or the organization I represent understand that any violation of any of these agreements will result in forfeiture of deposit, immediate termination of event, and jeopardize future use of City facilities. I and/or the organization I represent agree to indemnify, defend, and hold harmless the City of Eugene, its officials, agents and employees from and against any and all claims, damages, losses and expenses, including legal fees arising in and from my activities and/or those of the organization I represent during the term of the use of City park facilities. I and/or the organization I represent agree to pay all reasonable costs of damage and/or vandalism to the park of facilities used in relation to the Event. * * ** No parking or driving on any park lawn. * * ** Signature Date FOR DEPARTMENT USE ONLY White - File APPROVED COMMENTS Green - User Yellow - Police PW Y N INT Pink - Suprvsr. DPS Y N INT Gold - Spec Events Mgr. SEM Y N INT