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'JUL. 18. 2011 4: 26FM *FIS S''PRlNGFHEIU I'' 3
<br /> DOCW1A )
<br /> 4. Payment of banner permit fees MUST be included when the application is submitted:
<br /> (Banner applications can be faxed in if using a credit card. Fax 682-4879) • Fees are non-refundable
<br /> Description of fee Amount Cash =Check
<br /> ,visA is 641 ?AGA- t joc t33"7
<br /> Basic charge $35.00 NAME ON CARD Avir1t_'.1 /Illrzetoin
<br /> Administrative fee (7%) $ 2.45 Expiration date 001/2-0
<br /> Total (pay this amount) $37.45
<br /> 5. Conditions of Approval:
<br /> Banner specifications: Permittee is responsible for following all specifications established by the City for
<br /> banners. information regarding the specifications is attached to this application form and is available at
<br /> Public Works Maintenance. Failure to follow specifications may void City's approval of banner application.
<br /> Emergency removal: In the case of emergency removal or failure to remove the banner(s) at the
<br /> scheduled time, the City will contact the organization (permittee) and/or the permittee's listed installer. If the
<br /> City is required to remove any banner(s), the applicant will be required to cover the City's removal and
<br /> storage costs.
<br /> Insurance and indemnification requirements: The organization named in this application, hereafter
<br /> referred to as Permittee, covenants and agrees to defend, indemrify and hold harmless the City of Eugene,
<br /> from any and all costs, claims, demands, suits, 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 $500,000 combined single limit per occurrence, for bodily injury, personal injury and property
<br /> damage. Such policy shall contain a contractual liability endorsement to cover Permittee's indemnification
<br /> obligations under this contract. The policy also shall contain an endorsement naming the City of Eugene as
<br /> an additional insured, in a form satisfactory to City. Proof of such insurance is required by the City
<br /> when the application is submitted. a• .::11'��t• �c�1��,; >`u'���yrtr';,}�' +;2
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<br /> 6. Sign the application (signature indicates you are a ;P • 44.4'G itpnlj '� N'; � z'i,nM 'li
<br /> representative of the requesting organization):
<br /> I have ad and agree to the terms and conditions detailed under section#5.
<br /> Signatu Date "1 il$ ti
<br /> Title or position in organization e4y ✓1 + 'e--
<br /> 7. Income lete A.•lications will not be •rocessed and will be returned to a• •licant.
<br /> •
<br /> ;, .`N' :A—..r.,,_ -.•?;,-,°Y-,�`!`•.1_'=' *�•,•h.,_�.j:/,(.'';4;C,'.;'Y+r•,�,4•'�;;,U"'•.;?•'r-,_wSt°+Lo;,1'r;:Rbi:,•��,'4nN�',4.}'�1I"Ipia+;'h,,.�.`�i•t'Y�.t}t,x'kL14f,f�p,:°�i,+�Jhi.Jj".,,9,�'}4 S. Return application to: ; 4h tJ}.•w.e4ti
<br /> Public Works Maintenance hi :;},�?,•,�., a'114:
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<br /> ''•.•, . .1EUGENE ; • , ` •, ;. 114:•k
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<br /> Attn: Banner Program �)1' '•
<br /> 9
<br /> 1820 Roosevelt Blvd. w '•,;i '' l} ,! : 4 ;
<br /> Eugene Oregon 97402 .^,.. l �A - ii ` :Y����m,, lhrh !Akikf;,Y;ti'}�^
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<br /> Phone: (54 i)G82-489G H r; mw." o, ,41Jr
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<br /> 'ax: (541)682-4879 i RpI ` E7tZQf 8f •: , ,I,J;?,W;xx, a
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<br /> Application cannot be modified in any manner. Banner application Foi.n/PWM November 17. 2011
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