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<br /> CITY OF EUGENE POS
<br /> 1820 ROOSEVELT BLVD
<br /> EUGENE.
<br /> 541G682R. 94812-4159 )r permit fees MUST be Included when the application Is submitted:
<br /> 1 be faxed In If using a credit card. Fax 682-4879) Fees ere non-refundable
<br /> Phone Order Amount a Cash a Check
<br /> zzzzzzzzzzzz1603 - X VISA c MC _ 4100 4000 2214 1603
<br /> $35
<br /> VISA Entry Method: Manual .00 NAME ON CARD Allan Benavides _
<br /> Total: 112.35 — $ 2'45 Expiration date 09/20
<br /> 0503/17 07:56:33 . $37.4
<br /> Inv t: 0 000001 Apar Code: 027810 val: f I)7125- ' _ 3/P--- 3
<br /> APPrvd: Online ermittee is responsible for following all specifications established by the City for
<br /> AVS Code: arding the specifications is attached to this application form and is available at
<br /> CVV2 Code: NOT PROCESSED P . Failure to follow specifications may void City's approval of banner application.
<br /> Cu5to"« C pY the case of emergency removal or failure to remove the banner(s) at the
<br /> THANK YOU! ii contact the organization g (permittee) and/or the permlttee's listed installer. If the
<br /> any banner(s), the applicant will be required to cover the City's removal and
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<br /> THANK YOU! (cation requirements: The organization named in this application, hereafter
<br /> )venants and agrees to defend, indemnify and hold harmless the City of Eugene,
<br /> aims, demands, sults, actions, judgments, and recoveries for or on account of
<br /> damage or injury, Including death, to property or person to Permittee, its agents, servants or volunteers, and
<br /> to all members of the public, caused by or arising out of the Installation or display of the described banner.
<br /> Permittee agrees to pay all replacement costs for damage to City facilities or equipment resulting from the
<br /> installation or display of the described banner, City does not assume any responsibility for the condition of
<br /> facilities or equipment used.
<br /> Permittee shall maintain a commercial general and auto liability Insurance policy with coverage of not
<br /> less than $500,000 combined single limit per occurrence, for bodily Injury, personal injury and property
<br /> damage. Such policy shall contain a contractual liability endorsement to cover Permlttee's indemnification
<br /> obligations under this contract. The policy also shall contain an endorsement naming the City of Eugene as
<br /> an additional Insured, In a form satisfactory to City. Proof of such Insurance is required by the City
<br /> when the application Is submitted. ,-. --..7--2.., .„ ., ,1: j ,.a.,.,•. 7^ . :.
<br /> 6. Sign the application (signature indicates you are a F,.�oi ,IQf_1•r sur . l ovic1e ;T ,04;? t- j o'�.
<br /> 41,
<br /> representative of the requesting organization):
<br /> I have read as• y,re t s and conditions detailed under section #5.
<br /> Signature /411F4/11/17
<br /> Date
<br /> Title or position In organization General Manager
<br /> 7. Incomplete Applications will not be p oceased :nd will •j returned t a. .11cant.
<br /> 8. Return application to: N. r! > , „ •; yt F PP ` (1L )GE , ;fi t t{ ,l' �, ,Y � xa �,
<br /> Attn: Banner Program 3; u `' 4r \� -• '.0 R iii. ,,K '' '•
<br /> 1820 Roosevelt Blvd. r� ' :, ° ; "' ' " d?:` `a,i�l r':.` v ` •-,*‘." 4, L '. a,' +' ` 4'
<br /> Eugene Oregon 97402 1'? 17e X) "`. �� '• .k r j e.. .. ' e•444,14, ,NP i.
<br /> Phone: (541)682-4896 `�;h7wr224 ;• i' 4 , d,, r., ;au f,..!.. ' ,, 4",., .0'14. d •i', .; v
<br /> 879 _ .1,y -'� r `,
<br /> ,1•X1. 10. ,��� � .� �� ` ' s ,' .l,
<br /> Fax (5411682-4 ,rs-:1 t,r�.+•,a.,�; _:?� rA ..a.au il:..:: , '1'.t. "- i s,.-.
<br /> Application cannot be modified in any manner. Banner applitarion Form/PWM November 17,2011
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