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. NO REFUNDS! Statement of Intended Use of City Park City of Eugene Public Works Blvd. Bl Approval of this form does not constitute an exclusive reservation of public open space. Eugene, OR Roosevelt elt Bl Make sure you have the PARK RULES pamphlet and GUIDELINES FOR EVENT 1820 PLANNERS. (541) 682 -4800 Return Completed form to Public Works, 1820 Roosevelt for review by City staff. Once approved, your copy may be picked up at 1820 Roosevelt Blvd., Monday- Friday, 8:00 AM - 5:00 PM. Please have your copy of this form with you a your event, and remember to pick up your key prior to your event. NAME OF ACTIVITY "Ic. oA ' 1. PARK NAME & AREA (be specific) - "' 2. DATE TIME From :2;60 M d 11; ao AM 3. ESTIMATED ATTENDANCE LIW fu kw II4L,t. c i 4. WILL THIS EVENT BE ADVERTISED AS OPEN TO THE PUBLIC? ❑ YES $ NO IS THIS EVENT BY INVITATION ONLY OR FOR IDENTIFIED MEMBERS? VYES []NO 5. SPONSORING ORGANIZATION T Representative Name Phone 4,$?_ -'7$87 Address . City/Zip 97Lfol 6. TO BE COMPLETED BY APPLICANT (please check all that are applicable): ❑ Food will be served ❑ Food will be sold ❑ Alcohol will be served ❑ Alcohol will be sold ❑ Items will be sold ❑ Admission fees (voluntary or mandatory) will be collected • Booths, canopies, stages or other equipment (such as dunk tanks or "bounce" play areas) will be erected • Amplified sound will be used for LESS than 2 hours • Amplified sound will be used for MORE than 2 hours • Participatory and /or registered sporting activity such as a road run, bike race and/or walk ❑ Portable restrooms will be set up O'Vehicle access to park is requested (other than parking lot) 12 � /^ r jT �p 1 ther activities (list) _';k p� Oo�cri 5d, mss ,�l„r i� he4 ,/ e IF REQUESTING APPROVAL FOR AMPLIFIED SOUND OVER TWO HOURS: TIME From AM /PM to AM/PM SOUND PROVIDER 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 futule 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 fran 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 or facilities used in relation to the Event. NO PARKING OR DRIVING ON ANY PARK LAWN Signature Date �zZI7Le/ ANY CHANGES TO THIS PERMIT MUST BE SUBMITTED AT LEAST 48 HOURS PRIOR TO EVENT TO BE COMPLETED BY OFFICE: ❑ Standard Park Use ❑ Special Event Park Use Applicant must provide items required PRIOR to approval: Rec' d ❑ Certification from Lane County Environmental Health ®'Certificate of General Liability Insurance • OLCC Permit • Certificate of Liquor Liability Insurance R'Site Plan ❑ Route map for sporting activity ❑ Entertainment schedule for use of amplified sound DUE DATE: FEES: Security deposit to be paid separately ❑ Standard Park Permit AMT: PD: ❑ Special Event Permit AMT: PD: ❑ Facility User Fee AMT: PD: ❑ Security Deposit AMT: PD: ❑ Vehicle Permit Fee(s) AMT: PD: VOther a,", (Zp i tg � r 0� A4Z, ,' * 01 Ar —T ;7 0 7 - KEYS ISSUED: DATE: White - File APPROVED PW ON INT� Green - User APPROVED copy Pink - User copy (as submitted) COMMENTS /CONDITIONS: Statement of Intended Use of City Park, Revised 10/2000