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Standard Use and Special Use Permit Application
<br />City of Eugene
<br />The completed application foam Public Works
<br />' p pp ,required attachments, non - refundable d.
<br />1820 Roosevelt Blvd.
<br />permit fee, and any other fees must be submitted to Public Works at 1820 Eugene, OR Roosevelt Bl
<br />Roosevelt Blvd. A separate check for the security deposit is required.
<br />• Applications will be processed in order of receipt and will be approved
<br />or denied with 14 days of receipt unless the Executive Director or designee extends th D
<br />processing period by an additional 14 days by written notice to the applicant. APR 2 1 2006
<br />• ` "~3f, after submission of an application but before a decision is rendered, the applicants its additional
<br />application materials, a decision will be rendered within 14 days of receipt of the addi ' Ral materials.
<br />• Permit decisions will be mailed to the applicant at the address below. and Use 0
<br />t f Special Use X 1. Name of event: 0 i� 7 P t �i : to) , * .'Aa l t r� tic r k r f
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<br />2. Requested park, open space or park facility (be specific): u> k P le It , ! a u a t), , r4 . 49
<br />S[-� ��tiN.i�U'.�! it�� f1�f1 <,�:. �Gy¢.:i,✓�� ji:W 1'f;�.rl'7, � ✓T�
<br />3. Date: Ar ycM , G Mi 4 �0 0 A Time: from A to I IT Estimated Attendance: _ y
<br />4. Event Sponsors: �� C 1 g O r 1 , r I r I �k tt,S e tt y, y P l t, d a r l u k4_ /
<br />Representative Name: r t, 1 i,( Phone:
<br />Address: v- L art'► S In K W v A9 ✓ 0)e 1 J e C J , 4q g l _
<br />E-Mail Address: r LG to S G r,e kt c Q 6 l
<br />5. Will this event: (If the answer is yes to any of the questions below, you must obtain a Special Use Permit.)
<br />A: Have a controlled admission (i.e., require an admission fee)? jKYES O NO
<br />B. ,,,, Require the erection of canopies, tents, booths, or stages? 0 YES A( NO P k rA 5 K
<br />C. 'Be advertised as a public event? X YES 0 NO
<br />D. Amplify sound for more than two hours? 0 YES -fiKNO
<br />E. Use a park or open space facility as a stagii site for a public event that exceeds
<br />the capacity of the rental facility? 0 YES NO
<br />6. Will food be served, sold, or given away? 0 YES N0' (If„ .des, ,you must provide the City with a copy of a
<br />temporary restau imt license from Lape County Environmental Health at least 20 days prior to the date of the, event.)
<br />4,
<br />7. Will alcoholic beverages be sold dr s free .of ohate? D., �NO (If yes, you must comply with the
<br />applicable insurance and OLCC licens is seto in�A Order 58- 03 -24-F, Rule 1.004(3).)
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<br />L Will goods or services be sold? 0 YES *NO (If yes, you must comply with Administrative Rule 1.004(5).)
<br />9. WM equipment, booth, garbage boxes, portable restrooms, or a stage be brought to the site? )(YES 0 NO
<br />(If yes, this application must be accompanied by a site plan for the park/open space.)
<br />10. Will amplified sound be used for more than 2 hours? 0 YES X NO (If yes, this application must be
<br />accompanied by a schedule of entertainment.)
<br />11. Will the park or open space be used to hold a racetwaMike event? 0 YES - XNO (If yes, this application must
<br />be accompanied by a route map for the park and streets.)
<br />12. h attendance anticipated to exceed 500 people ?*YES 0 NO (If yes, this application must be accompanied by
<br />a certificate of insurance that complies with Administrative Order No. 58- 03 -24-F, Rule 1.004(2xa). Also, if yes,
<br />you must provide security and traffic control personnel for the event in compliance with Administrative Order No.
<br />58- 03 -24-F, Rule 1.004(6) and this application must be accompanied by a traffic control plan.)
<br />13. All applicable fees must be submitted with this application. Permit fees are non - refundable. If an event is
<br />canceled, facility rental fees are refundable in the manner prescribed by Administrative Order of the City Manager.
<br />0 Standard Park'Permit Fee: $ Special Event Permit Fee: $ '�T
<br />0 Facility User Fee: $ 13 Security Deposit (Separate Check): $
<br />0 Vehicle Permit Fee(s): $ 'St ,Other ;, 4 ) �J ��1, u ev e L4 1A 2
<br />I, `' Lia 1%J c1 �, tj d S , am the permit applicant. I certify that I am an authorized representative of the
<br />above organization (if any). I certify that the above statements are true to the best of my knowledge. I have received a copy
<br />of Administrative Order No. 58- 03 -24-F, Park and Open Space Rules, and I and/or the organization I represent agree to be
<br />bound by all applicable regulations. 1 and/or the organization I represent understand that any violation of any of these
<br />Agreements will result. in forfeiture of s
<br />agrrom epo it, immediate termination of went, and jeopardize future use of City facilities.
<br />is organization I represent agree to indemnify, defend, and hold harmless the City of Eugene, its officials, agents
<br />'and employees from and against any and all claims of injury to property or persons that may arise as a result of any activity
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<br />occurring at the event for which I seek this permit. I and/or the grganization I represent agree to pay all costs damage
<br />and/or vandalism to the p or facilities used in relation to the event for which I seek this permit.
<br />Signature Me Print Name
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