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CITY Ot tutitNE POS <br /> 1820 ROOOSSE 97T BLVD 0.00.07: / <br /> EUr£N5• / <br /> 591 682 4812 , • <br /> !1 <br /> I I <br /> Phone Order �' <br /> XxxxxxxxXXxx i JOJ <br /> VISA Entry Method: Manual nt of banner permit fees MUST be included when the application is submitted: 31` — <br /> plications can be faxed in if using a credit card Fax 682-4879 — <br /> Total: $ 37.45 if fee AmountI,v Cash heck/VAMC ,} <br /> 01/09/18 11:x:11 $35.00 NAME ON CARD ( 1 e(-CV ) f t. 1- t L 1 <br /> 11).441s1'�SiS4', <br /> API Code: CI fee(7°!) — S 2 45 Expiration date <br /> PPM: Online ;amount) S37.45 <br /> AVS Code: of Approval: <br /> CVV2 Code: HOT PROCESSED P :ations: Permittee is responsible for following all specifications established by the City for <br /> tation regarding the specifications is attached to this application form and is available at <br /> c..1St Oilier Cop' intenance Failure to follow specifications may void City's approval of banner application <br /> THAW YOU' <br /> loyal: In the case of emergency removal or failure to remove the banner(s) at the <br /> he City will contact the organization(permitted)and/or the permittees listed installer If the <br /> to remove any banner(s). the applicant will be required to cover the City removal and <br /> Meri.hant Cops <br /> THAW YOU, indemnification requirements: The organization named in this application. hereafter <br /> ..rmittee, covenants and agrees to defend indemnify and hold harmless the City of Eugene. <br /> 'I costs, claims. demands. suits. actions, judgments, and recoveries for or on account of <br /> .,a<..dye o. .iquiy. 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 Permittees 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 t:- :-h iris e is r, '^d by the <br /> when the application is submitter. <br /> City Use Only <br /> 6. Sign the application(signature indicates you are a Proof of insurance provided' 7 Yes ❑No <br /> representative of the requesting organization): <br /> I have read and agree to the terms and conditions detailed under section#5. <br /> Signature— ''>, Date r , t C. <br /> Title or position in organization _ to _��'. / 61 G IA �/.0 14/1"' J <br /> 7. incomplete Applications will not bel- •,.. , .-cd and will • ' ,rued to applicar, . <br /> 8. Return application to: � <br /> Public Works Maintenance (excra <br /> Attn:Banner Program City Use Only <br /> 1820 Rooselelt BI%d. <br /> Eugene Oregon 97402 Approved Date <br /> II Phone:(541)682-4896 <br /> Fax:i 541)682-009 0 Applicant notified Date <br /> 4110.<tli.,n anus,-be nu tified in<ure w.Binrr. tkrinrr cyy,lt.,,ivoi I,,rm lit 11\„crmhrr 1'.2n1 I <br /> 1 <br />