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Standard Use and Special Use Permit Application R <br />JAN - YO - <br />City of Eugene 2 <br />.__ <br />The completed application form, required attachments and <br />Public Works <br />non - refundable permit fee must be submitted to Public Works, 182 J Roosevelt. <br />1820 Roosevelt Blvd. <br />s <br />• Applications will be processed in order of receipt and will be granted or <br />Eugene. OR 97402 <br />(541) 682 -4800 <br />denied with 14 days of receipt, unless the Executive Director or designee extends <br />'he processing period by an additional 14 days by written notice to the applicant. <br />If, after submission of an application but before a decision is rendered, the <br />.pplicant submits additional application materials, a decision will be rendered within <br />Standard Use ❑ <br />14 days of receipt of the additional application materials. <br />Special Use 4 <br />• Permit application decisions can be picked up at 1820 Roosevelt Blvd. (Mon. - <br />Fri., 8 - 5). Permit denials will be mailed to the applicant at the address given below. <br />A RT ' <br />1. Name of event: AND TNtr VtNE\/Aw - <br />2. Requested park, open space or park facility (be specific): (.�q►GE�,�{L�� <br />-�•��^^ II 2 ('fSA7 <br />3. Date:dtI 1 . 2 4 ET Time: from *J A H to 10 00 4 Estimated Attendance: 0� <br />4. Event Sponsors: M , A U I)E Q-F�N - / K� ,{ �.N S A9 <br />K <br />Representative Name: A I"I V� ' hone:3 ' ; r <br />Address: I I o I A ve - City /Zip: .1. C� 14C- 91 1 10 <br />�. 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 ?,X YES ❑ NO <br />B. Require the erection of canopies, tents, booths or stages? � YES ❑ NO <br />C. Be advertised as a public event? AYES ❑ NO <br />D. Amplify sound for more than two hours ?,K YES ❑ NO <br />E. Use a park or open space facility as a staging site for a public event that exceeds <br />the capacity of the rental facility? ❑ YES K NO <br />6. Will food be served, sold or given away? YYES ❑ NO (If yes, you must provide the City with a copy of a <br />temporary restaurant license from Lane County Environmental Health at least 20 days prior to the date ofthe event." <br />7. Will alcoholic beverages be sold or served free of charge? X YES ❑ NO (If yes, you must comply with th <br />applicable insurance and OLCC license requirements set forth in Administrative Order 58- 03 -24 -F. Rule 1.004(3)., T <br />8. Will goods or services be sold ?RYES ❑ NO (If yes, you must comply with Administrative Rule 1.004(5).) <br />9. Will equipment, booth, garbage boxes, portable restrooms or a stage be brought to the site? 18 YES ❑ 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 or less than 2 hours)? N YES ❑ NO (If yes, this application must be <br />accompanied by a schedule of entertainment.) <br />Will the park or open space be used to hold a race /walk/bike event? ❑ YES A NO (If yes, this application mu- <br />be accompanied by a route map for the park and streets.) <br />12. Is attendance anticipated to exceed 500 people ?-N1 YES ❑ NO (If ves, this application must be accompanied <br />a certificate of insurance that complies with Administrative Order No. 58- 03 -24 -F, Rule 1.004(2)(a). Also, if <br />you must provide security and traffic control personnel for the event in compliance with Administrative Order P <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 ever <br />ca <br />, goeled, facility rental fees are refundable in the manner prescribed by Administrative Order of the City Mane <br />Standard Park Permit Fee: $ 2S. oa -Ek'<pecial Event Permit Fee: $ <br />12tacility User Fee: $ P2.n L yu 1 C 6'I 1 V1IN _ V Security Deposit: $ 2- 00 <br />❑ Vehicle Permit Fee(s): $ J 'o 4L ❑ Other <br />�I ) t .0 <br />1. iPe 0 4 l TAVEU- G am the permit applicant. I certify that I am an authorized representative <br />above organization (if any). I certify that the above statements are true to the best of im knowledge. I have received <br />of Administrative Order No. 58- 03 -24 -F, Park and Open Space Rules. and I and /or the organization I represent agret <br />bound by all applicable regulations. I and /or the organization I represent understand that any violation of any of <br />, preements will result in forfeiture of deposit, immediate termination ofevent, and jeopardize future use of City lac <br />and /or the organization I represent agree to indemnify, defend, and hold harmless the City of Eugene. its officials, agemN <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 <br />occurring at the event for which I seek this permit. I and /or the organization I represent agree to pay all costs of damage <br />and /or vandalism to t ark or facilities used in relation to the event for y yhich I seek this pernnit. <br />Ott IJ_D.1_.l E� 1 C A►t0� oerlS <br />Sign Da �� P 'nt Name <br />