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• CITY OF EUGENE FOS 1820 ROOSEVELT BLVD EUGENE, OR. 97402-4159 541-682.4812 Phone Order xxxxxxxxxxxx5611 banner permit fees MUST be included when the application is submitted: v'ISA Entry Method Manual :ions can be faxed in if using a credit card. Fax 682-4879) ;�025 are non-rerundable Amount Cash Check Amount:$ 37.45 VISA MC _ _ Tax: $ 0.00 $35.00 NAME ON CARD "1 NAc GkkYI?, rks Total: $ 37.45 (7%) $ 2.45 Expiration date 014948 08:10:53 nount) $37.45 Inv IM: 1;1,11 11 APAr Code: 037493 f Approval: APPrv,, Online Lions: Permittee is responsible for following all specifications established by the City for AVS Code: tion regarding the specifications is attached to this application form and is available at CO2 Code: NCI PROCESSED P ,tenance. Failure to follow specifications may void City's approval of banner application. cU.t0,c, COPY )vat: In the case of emergency removal or failure to remove the banner(s) at the THANK VW e City will contact the organization (permittee) and/or the permittee's listed installer. If the remove any banner(s), the applicant will be required to cover the City's removal and Merchant COPY ndemnification requirements: The organization named in this application, hereafter THAW( YOU! mittee, covenants and agrees to defend, indemnify and hold harmless the City of Eugene, costs, claims, demands, suits, actions, judgments, and recoveries for or on account of 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 c r when the application is submitted. City Use Only 6. Sign the application (signature indicates you are a Proof of insurance provided: ❑Yes El No representative of the requesting organization): I have read and agree to the terms and conditions detailed under section#5. Signature 1 4j '.ndr'� Date_ 1� �a j 1 Title or position in organization ( jliQ_ Syctik t- * \l 7. Incomplete Applications will not be processed nd will be refer 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:(5411682-4879 ❑Applicant notified Date Application cannot be modified in any manner. Banner application Form/PWM November 17,2011