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CITY OF EUGENE POS
<br /> 1820 ROOSEVELT BLVD
<br /> EI!<i DR. 94812-4159 �{0���� AIMA ./�+�r
<br /> / 541i2 4812 C\VN
<br /> Phone Order ct v- a 1E `va kop.
<br /> xxxxxxxxxxxxos nner permit fees MUST be included when the application is submitted:
<br /> MASTERCARD Entry Method; Manual
<br /> can be faxed In if using a credit card. Fax 682-4879) Fees are non-refundable
<br /> Amount Cash c.Chec
<br /> Amount:$ 37.45 VISA •mac - .._ -
<br /> Tax: $ 0.00 $35.00 NAME ON CARD \Y16SQl' SRAGRI
<br /> Total: $ +^ 37.45 I) $ 2.45 Expiration date Illar______:1 .
<br /> 0118
<br /> 11:63:34 nt) $37.45
<br /> Inv a: ,s; 1, Roar Code: 661635 proval:
<br /> Aaarvd: Online c: Permittee is responsible for following all specifications established by the City for
<br /> AVS Code: regarding the specifications is attached to this application form and is available at
<br /> nce. Failure to follow specifications may void City's approval of banner application.
<br /> Customer Coal, •
<br /> THANK YOU! In the case of emergency removal or failure to remove the banner(s) at the
<br /> y will contact the organization (permittee) and/or the permittee's listed installer. If the
<br /> love any banner(s), the applicant will be required to cover the City's removal and
<br /> Merchant COPY
<br /> TtwMK YOU! lemnification requirements: The organization named in this application, hereafter
<br /> ttee, covenants and agrees to defend, indemnify and hold harmless the City of Eugene,
<br /> 3sts, 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 $500,000 combined single limit per occurrence, for bodily injury, personal injury and property
<br /> damage. Such policy shall contain a contractual liability endorsement to cover Permittee's indemnification
<br /> obligations under this contract. The policy also shall contain an endorsement naming the City of Eugene as
<br /> an additional insured, in a form satisfactory to City. Proof of such Insurance is required by the City
<br /> when the application is submitted. yy: 4 e " `}- y P
<br /> i.y � �� '-� � ��1-2,' ",-..4:,,--
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<br /> 6. Sign the application (signature indicates you are a Proof of insu nrcL'' s4,4F0
<br /> 44
<br /> representative of the re:uesting organization):
<br /> I have a -nd agree th 1 terms and conditions detailed under section#5.
<br /> Signatur• 1 01 V.I.! Al . + r Date it I'IS t 19'"
<br /> Title or posi on hi org• ization TrA1'\SpO I(•�"olrkwaper. -IF
<br /> o n Cr O AS o0 f c \ f1c1-\D c
<br /> 7. Incomplete Applications will not be processed and will be returned to applicant.
<br /> 8. Return application to: + :-
<br /> Public Works Maintenance i r ,-r etw.,,,g�
<br /> a' 7,,,,,,---',=. ?x
<br /> Attn:Banner Program f �-.*--.-` ':.4?",-,; ' �f tf " 4 " a > x , '; ,
<br /> 1820 Roosevelt Blvd. �,* . ,,'1-'‘-‘,x
<br /> „a tY.. ” %
<br /> F r
<br /> �T o}o)Ma$"/sod �r $ Y 0 ' Sa '.K.w e t
<br /> Eugene Oregon 97402 ,-.' -.--,...77r ; : s`¢,t "4,y ,_,- •,, .' = -' r�
<br /> Phone: (541)682-4896 Q- _ •,',7,--',.,1•1+. 1 - ;
<br /> Fax (541)682-4879 L.-. ,-...- r u.int l _._.._ ._1..s,i ___ ,7 _:�, :�. _--_-24.___.'
<br /> Application cannot he modified in any manner. Banner application Fornr/PWM November 17,2011
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