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0 <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 Ghee' <br /> XV1SA MC _ 1 <br /> Basic charge $35.00 <br /> NAME ON CARD SALL-+6 LC.(t b0/iJ <br /> Administrative fee (7%) $ 2.45 <br /> Expiration date_ - <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, indemnify 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. <br /> City Use Only <br /> 6. Sign the application (signature indicates you are a Proof of insurance provided:❑ Yes ❑ No <br /> representative of the requesting organization): <br /> I have read and a•ree to the terms and conditions detailed under section#5. <br /> Signature /,e ' / Date /a/.5 l/'7 <br /> Title or positio in /rganization '/}7(ir'140 <br /> 7. Incomplete Applications will not be processed and will be returned to applicant <br /> 8. Return application to: <br /> Public Works Maintenance = !�I <br /> ELIA <br /> Atm: Banner Program City Use Only <br /> 1820 Roosevelt Blvd. <br /> Eugene Oregon 97402 Approved Date <br /> Phone:(541)682-4896 <br /> Fax:(5411682-4879 ❑ Applicant notified Date <br /> Application cannot be modified in any manner. Banner application Form J' M November 17.2011 <br />