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CITY OF EUGENE POS
<br /> 1820 ROOSEVELT BLVD
<br /> EUGENE OR. 97482-4159
<br /> • f 0 ar�.{r.�vt,1/4“ , (�,rd
<br /> 541-G82-4812 , C.:1
<br /> Phone Order '14 vq_ a 7E coc\-0-co.
<br /> z�cz>ocz:cXzzX> ner permit fees MUST be included when the application is submitted:
<br /> an be faxed in if using a credit card. Fax 682-4879) Fees are non-refundable
<br /> NERCO Entry Method: Manual Amount D Cash n check —
<br /> Amount:$ 37.45 n MA . Mc ' - __ _ SOW
<br /> —
<br /> Tax: $ 0.00 $35.00 NAME ON CARD I.,�Y1C�S0�� �7�,�1
<br /> $ 2.45 ;►�
<br /> %!':;' ''
<br /> II
<br /> Total: $ 37.45 Expiration date
<br /> t) $37.45 -1
<br /> 0118 11:02:47
<br /> Inv 4: =n, Poor Code: 899160 -oval:
<br /> APDrvd: Online Permittee is responsible for following all specifications established by the City for
<br /> AVS Code: 3arding the specifications is attached to this application form and is available at
<br /> e. Failure to follow specifications may void City's approval of banner application.
<br /> Customer Cove
<br /> THANK You, I the case of emergency removal or failure to remove the banner(s) at the
<br /> till contact the organization (permittee) and/or the permittee's listed installer. If the
<br /> 9 any banner(s), the applicant will be required to cover the City's removal and
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<br /> Merchant Cove ication requirements: The organization named in this application, hereafter
<br /> TANK ARPwenants and agrees to defend, indemnify and hold harmless the City of Eugene,
<br /> rims, demands, suits, actions, judgments, and recoveries for or on account of
<br /> death, to property or person to Permittee, its agents, servants or volunteers, and
<br /> air 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, t r,
<br /> 3` 3 rS L
<br /> 6. Sign the application (signature indicates you are a ,)?roof o nsuFarfce. cov ed.0•'r s 0 No '
<br /> representative of the re.uesting organization):
<br /> I have r:i'd -nd agree '1 th:.terms and conditions detailed under section#5. •
<br /> SignaturE 1 / .���,1...1 All . 1 Date 11 `' — t UR--
<br /> -
<br /> –
<br /> Title or posi on in org ization �rCktYTO('}ani c V C, .- 111 S W 0(( 1 i1GL�c
<br /> 1
<br /> 7. incomplete Applications will not be processed and will be returned to applicant.
<br /> 8. Return application to: i � ;. - 1 e .-4
<br /> Public Works Maintenance 2 ;� : t- ` -Nigh "` ` „,...:77----
<br /> 7, 5
<br /> .� 1P`- EUGENE «y _.,,.-2.4,:'_4cY1k 7 -.t
<br /> Attn:Banner Program i�-,,<_ t4�- t '�S�e : F
<br /> 1820 Roosevelt Blvd. 3 -, ; �� � ' y X
<br /> Eugene Oregon 9 402 +F e p oV irk r -.-,--s,� iDbt c' r - r
<br /> Phone:(541)682-4896 * - - 1 , p '- - -- -
<br /> ty.o o t - urs < l 3 ?:�r
<br /> Fax (541)682-4879 k 4 = , �7 x 1J.1....-1, -;.-.--.;:i.4- i,',4,-,mo ' ,
<br /> Application cannot be modified in any manner. Banner application Form/PWM November 17,2011
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