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i CITY OF EUGENE POS 1820 ROOSEVELT BLVD EUGENE. OR. 97402-4159 541682-4812 Phone Order zzzzzzzzzzzz inner permit fees MUST be included when the application is submitted: VISA Entry Method: Manual s can be faxed in if using a credit card. Fax 682-4879) Fees are non-refundable Amount )o Cash ❑Check . Total: $ 112.35 ISA oMC — 0140948 08:12:01 $35.00 NAME ON CARD �� DOI>O e jc?�u�I Inv if: !!=!, tar : 01'N /o) $ 2.45 Expiration da APPrvd: Online unt) $37.45 X ' + NS Code; C 3 pe ort.4--s ��' CW2 Code: N01 PROCESSED P pproval: • Is: Permittee is responsible for following all specifics • ablished by the City for Custo.er COPY i regarding the specifications is attached to this application form and is available at THAN( YOU! ance. Failure to follow specifications may void City's approval of banner application. I: In the case of emergency removal or failure to remove the banner(s) at the _ _______ :ity will contact the organization (permittee) and/or the permittee's listed installer. If the �""""""'"�"��-��__ _____- move any banner(s), the applicant will be required to cover the City's removal and Merchant COPY THAN( YOU! .mnification requirements: The organization named in this application, hereafter ae, covenants and agrees to defend, indemnify and hold harmless the City of Eugene, from any and all costs, claims, demands, suits, actions, judgments, and recoveries for or on account of damage or injury, including death, to property or person to Permittee, its agents, servants or volunteers, and to all members of the public, caused by or arising out 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 read and agree to the terms and conditions detailed under section#5. Signature Date Title or position in organization 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 1 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