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licationroenon-refundap1e <br /> UST be included when the app e c, <br /> 682-4879 <br /> neer faxed <br /> fees Mn. a credit card.Fax - "Y <br /> ed in if �.Chec,. <br /> 5 <br /> can be fax amount VISA r MC <br /> Cllr VC 7 is12 9 <br /> E�N CARD,� $41(32.2.aa�z X35.00 NAM <br /> led <br /> der $ 2.45 Expiration da <br /> e Or b the City for <br /> Qhon $37.45 <br /> , established is available at <br /> tihod•,l'itNi 1) ecifications form and <br /> til Entry all sP lication application. <br /> xxxxxxxxxxxx08 31 .45 royal: responsible for following to this app <br /> V1SA Permittee is resp ns is attached void City's approval of banner app <br /> s at the <br /> tal; � tlD�.13',01 Perm the specificatiothe banner( ) <br /> ° arding s ecifications may remove installer. If the <br /> far Code,D19D31 e Failure t follow P failure to ,s listed oval and <br /> D1iVc)i APt emergency removal or ermitteethe City's rem <br /> lav it',S' of egani (permittee) andlor the P cover <br /> a, Dn1�ne the case anieation (P re uired to <br /> \PP�� � the applicant will be q <br /> PVS Code' ��pRpCESSED P gill contpanner(s) hefeafter <br /> CVV2 CoaC e any this application, ene, <br /> � in <br /> named u <br /> :'`°° The organization oust of <br /> nN� `'�. requirements: and hold harmless the C n aCc <br /> ication req a fees to defend, indemnity and recoveries for or <br /> servants or volunteers, and <br /> __ ----- - ovenants and g suits, actions, judgments,its agents, <br /> --------- aims, ,to prop or person to Permittee, of the oevoluntee s,from the <br /> ^�''"�� eath, e by or equipment resulting <br /> out of the displayinstallaticon or'litiesor eq �P the condition of��n�..t CO� °' 1 or arising e to City fa for <br /> ic, caused by responsibility <br /> ner. <br /> 1►r�vw meet costs for damage I replace does not assume any <br /> of the described banner. City olio with coverage of not <br /> ,,,�.auc+u�lr� or airplay insurance policy property <br /> facilities or equipment used. personal injury <br /> commercial general and auto liabilityrodity injury, P <br /> single limit per occurrence, City of and prEugoperty <br /> as <br /> ' ee shall maintain a com sendorsement to cover Permittee's indemnification <br /> Permittee the <br /> J ::: <br /> vll'jlless than $500,000 combinedSucd r th sy char contain a contractual ali oy ndor i m nae. he olicy also shall contain an endorsement namingdamag to City•obligations ander this COnQto form sati factory Cityz. <br /> UseOnlyan additional insured,MMaa, the application is submitteu <br /> 6 Sign the application (signature indicates yon areaProof of insuranceprovided: ❑ No <br /> representative of the requesting organization): <br /> I have read and agree to the terms and condi:ions detailed under section#5. <br /> Date fit 6Le / i7 <br /> Signatu . <br /> Title or position in organization <br /> t I , <br /> . ; � , <br /> 7■ I/71t;Ciff`r!i)lete Aonlications will flat hp nrnraccarl am will ha rt,tptrnarl trs anr.liv+-,,.1t <br /> 8. Return application to: ` <br /> Public Works Maintenance <br /> E6� G'£� <br /> Atte: Banner Program City Use Onl <br /> 1820 Roosevelt Blvd. y <br /> Eugene Oregon 97402 Approved Date <br /> Phone:(541)682-4896 ---- <br /> Fax: (541)682-4879 ❑Applicant notifid Date <br /> /ApP ca io <br /> cannot be modifred in any manner. <br /> Balm, <br /> -..r <br /> Forryl/PO <br /> Nobe„,i, i <br /> l'uft17 ti 4 / <br />