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R <br />Have a controlled <br />Standard Use and Special Use Permit Application <br />Require the erectii <br />JAN ' 2 - 10 <br />City of Eugene <br />_ =- <br />• The completed application form, required attachments and <br />Public Works <br />1820 Roosevelt Blvd. <br />non - refundable permit fee must be submitted to Public Works, 1827 Roosevelt. <br />Eugene, OR 97402 <br />• Applications will be processed in order of receipt and will be granted or <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 aSl <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 />\ <br />A V- - r <br />1. Name of event: AND THI= V i wc�,jAl2D <br />�l <br />2. Requested park, open space or park facility (be specific` <br />� <br />3. Date:dt+� �t Time: from <br />4. Event Sponsors: F <br />Representative Name: VA <br />2004 Park Rentals <br />Address: n I' <br />Friday, January 2, 2004 <br />A;. Will this event: (If the answer is } o an <br />A. <br />Have a controlled <br />B. <br />Require the erectii <br />C. <br />Be advertised as a <br />D. <br />Amplify sound for <br />E. <br />Use a park or open <br />the capacity of the <br />6. Will food be served, sold or give <br />temporary restaurant license from L <br />7. Will alcoholic beverages be sold i <br />applicable insurance and OLCC lice. <br />8. Will goods or services be sold ?RYES ❑ NO (If <br />9. Will equipment, booth, garbage boxes, portable r <br />(If yes, this application must be accompanied by a si <br />10. Will amplified sound be used (for more or less the <br />accompanied by a schedule of entertainment.) <br />Will the park or open space be used to hold a raceb <br />be accompanied by a route map for the park and stref <br />12. Is attendance anticipated to exceed 500 people ?-i!( <br />a certificate of insurance that complies with Administ <br />you must provide security and traffic control personm <br />58- 03 -24 -F, Rule 1.004(6) and this application must E <br />Key and Security Depos'� <br />Event Name i h &L t� <br />Name t1 t, 6' l L <br />L'ILD f'Gt VZI L C. - <br />Address iii (d C �' l j Ave � <br />Phone_ �� — <br />I <br />Key Number n. <br />Location J � <br />` <br />13. All applicable fees must be submitted with this a[, Deposit VY a-GO -00 <br />ca ed, facility rental fees are refundable in the mannt <br />Standard Park Permit Fee: $ 2 ov Date issued <br />OTacility User Fee: $ _Q2. v Cl, t r Ct; {�l M - l� <br />❑ Vehicle Permit Fee(s): $ <br />p i to be returned , <br />am the permit applicant. issued <br />above organization (if any). I certify that the above statements are trut <br />of Administrative Order No. 58 03 - 24 - F, Park and Open Space Rules Public Works <br />p p Parks 8 Open <br />bound by all applicable regulations. I and /or the organization I repre. space Division <br />, vreements will result in forfeiture of deposit, immediate termination of <br />and /or the organization I represent agree to indemnify, defend, and hold ,..........�� urc v iry of Eugene, its officials, agents <br />and employees from and against any and all claims of injure to property or persons that may arise as a result of am activ its <br />occurring at the event for which I seek this permit. I and /or the organization I represent agree to pay all costs of dama_e <br />and /or vandalism to ark or facilities used in relation to the event for which I seek this permit. <br />if 06e I '0 A4c l P C Au4� -MM <br />L" <br />Sign Da e P 'nt Name <br />