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NO REFUNDS! , L N Ati wokrio Statement of Intended Use of City Park G , It Blvd. Approval of this form does not constitute an exclusive reservation of public open space ( 7402 Make sure you have the PARK RULES pamphlet and GUIDELINES FOR EVENT 1 i ' y' 0 PLANNERS. 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. ff NAME OF ACTIVITY E »ie"a ! r1'y7 %fL Heir e Ulk -� 1 � � 1. PARK N • E &• 1 A s e specific) A Ito k1 3' Ie f�Crr • 2. DATE t1 r I TIME From n 1OPM to 11 Ali PM 3. ESTIMAT . ' ATTENDANCE r W 4. WILL THIS EVENT BE ADVERTISED AS OPEN TO THE PUBLIC? /YES ❑ NO IS THIS EVENT BY 5. SPONSORING ORGA INVITATION ZATION ONLY � O'�OI� IDE; I t ME ;: E tS? 0 YES �NO Representativ Na e ".ti C �� /e �- Phone 5 " - 06" y 0 Address 1 1 1 ; t i 'WW1. City/Zip en e 6. TO BE COMPLETED BY APPLICANT (please check all that are applicable): 131 Food will be served liKood will be sold ❑ will be served riAlcohol will be sold e will be sold ❑ Admission fees (voluntary or mandatory) will be collected tliBooths, canopies, stages or other equipment (such as dunk tanks or "bounce" play areas) will be erected ❑ sound will be used for LESS than 2 hours Amplified sound will be used for MORE than 2 hours 0 Participatory and/or registered sporting activity such as a road run, bike race and/or walk 1 / Portable restrooms will be set up Vehicle access to park is equested (other than parki lot) �I sl Other activities (list) d1%i in Sma zwe.J 7. IF REQUESTING APPROVAL FOR AMPLIFIED to 11 AM/C) SOUND PROVIDER —J 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 or facilities used in relation to the Event. NO PARKIN OR DRIVING ON ANY PARK LAWN Signature Date 1 / r /OS ANY CHANGES TO THIS PERMIT MUST BE SUBMITTED AT LEAST 48 HOURS PRIOR TO EVENT TO BE COMPLETED BY OFFICE: 0 Standard Park Use Special Event Park Use Applicant must provide items required PRIOR to approval: FEES: 1� Rec'd Security deposit to be paid separately C rtification from Lane County Environmental Health ❑ Saf Park Permit AMT: PD: sate of General Liability Insurance 'Special Event Permit AMT: ZS °c: PD:IN 0 C Permit ❑ F'lity User Fee AMT: PD: � 4icate of Liquor Liability Insurance � Security Deposit AMT: 2.00 PD: O' j IM'S Plan ❑ Vehicle Permit Fee(s) AMT: PD: ❑ Rote map for sporting activity ❑ Other ntertainment schedule for use of amplified sound DUE DATE: KEYS ISSUED: DATE: White - File APPROVED PW Y N INT Green - User APPROVED copy Pink - User copy (as submitted) COMMENTS /CONDITIONS: Statement of Intended Use of City Park, Revised 10/2000