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CITY OF EUGENE POS 1820 ROOSEVELT BLVD EUGENE. OR. 97402-4159 541-682-4812 • Phone Order ler permit fees MUST be included when the application is submitted: xxxxxxxxxxxx2581 an be faxed in if using a credit card. Fax 682-4879) Fees are non-refundable MASTERCARD Entry Method: Manual Amount Cash i Check Amount:$ 37.45 ,VISA nhlIc 5A13..- (6s 4IA- 5 c7—�, 'i51 $35.00 NAME ON CARD L><S 111tA-c.. - Tax: $ 0.00 t) $37.45$ 2.45 � Total: $ 37.45 Expiration date ( / NW 15:29:18 Inv a: 000080003 Appy Code: 083851 'oval: kind: Online Permittee is responsible for following all specifications established by the City for :garding the specifications is attached to this application form and is available at AVS Cede: .-, Fa!! :—4- _-linw specifications may void City's approval of banner application. Cust mcr CoPr $• c removal or failure to remove the banner(s) at the THANK YOU, ','rmlttee) and/or the permittee's listed installer. If the t will be required to cover the City's removal and , I nrrLhdnT COPY ' ' organization named in this application, hereafter THANK YW+ nd, indemnify and hold harmless the City of Eugene, ns, judgments, and recoveries for or on account of to Permittee, its agents, servants or volunteers, and to all members of the public, car -,:-.• • - : of the installation or display of the described banner, Permittee agrees to pay all replacement costs for damage to City facilities or equipment resulting from the Installation or display of the described banner. City does not assume any responsibility for the condition of facilities or equipment used. Permittee shall maintain a commercial general and auto liability insurance policy with coverage of not less than $500,000 combined single limit per occurrence, for bodily injury, personal injury and property damage. Such policy shall contain a contractual liability endorsement to cover Permittee's indemnification obligations under this contract. The policy also shall contain an endorsement naming the City of Eugene as an additional insured, in a form satisfactory to City. Proof of such insurance is required by the City when the application is submitted. City Use Only 6. Sign the application (signature indicates you are a Proof of insurance provided: ❑Yes ❑ No representative of the requesting organization): - I have ;e/ and a r e to t mi and conditions detailed under section#5. Signatures d ' 1"140-�(- Date J l '2-icqVi-- .„.. Title or position in organization 7J'- v C 111 ra \1Qm --f-iFi 7. incomplete Applications will not be processed and will be returned to applicant. 8. Return application to: Public Works Maintenance EUGENE Attn: Banner Program City Use Only 1820 Roosevelt Blvd. Eugene Oregon 97402 Approved Date Phone: (541)682-4896 Fax: (541)682-4879 ❑Applicant notified Date Application cannot be modified in any manner. Banner application Form/PWMNovember 17,2011