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13361
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I:IIY OF EUGENE POS <br /> 1820 ROOSEVELT BLVD <br /> EUGENE. OR. 9?402-4159 <br /> 541-682 4812 <br /> Phone Order <br /> zzzxxxxxzxxz68S9 Danner permit fees MUST be included when the application is submitted: <br /> ms can be faxed in if using a credit card. Fax 682-487°' <br /> VISR Entry Method: Manual Amount Cash Check - <br /> Total: $ 37.45 XvisA Mc _ _ - . , y _ . <br /> 01�09/1S 11. 6.24 7% $35.00 NAME ON CARD \( ([ 1,/ L `5i)i i t i1--)) $ 2.45 <br /> Inv IIS lll.l,ls9 RPPr Code: 08746C Expiration date_ - <br /> ount) $37.45 <br /> RPPrvd. Online <br /> AVS Code: 4pproval: <br /> CVV2 Code. NOI PROCESSED P )ns: Permittee is responsible for following all specifications established by the City for <br /> in regarding the specifications is attached to this application form and is available at <br /> Cubt COPY •nance. Failure to follow specifications may void City's approval of banner application <br /> 1NANK IOU! <br /> al: In the case of emergency removal or failure to remove the banner(s) at the <br /> City will contact the organization (permittee) and/or the permittee's listed installer. If the <br /> A------------ <br /> 'emove any banner(s), the applicant will be required to cover the City's removal and <br /> Mwrchant COPY <br /> THANK VOW <br /> ......,e and indemnification requirements: The organization named in this application, hereafter <br /> referred to as Permittee, covenants and agrees to defend, indemnify and hold harmless the City of Eugene, <br /> from any and all costs, 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. City Use Only <br /> 6. Sign the application (signature indicates you are a Proof of insurance provided: LI Yes ❑ No <br /> representative of the requesting organization): <br /> I have read and agree to the terms and conditions detailed under section #5. <br /> ( \ /%"� Date i( —Lv / <br /> Signature -- i C <br /> Title or position i org nization I `-25 t - a t I, 1,,- ii‘,.._ n)i,1 AY <br /> 7. incomplete Applications will not be processed and will be returned to applicant. <br /> 8. Return application to: ��l <br /> Public Works Maintenance E`U 1 <br /> Attn: Banner Program City Use Only <br /> 1820 Roosevelt Blvd. <br /> Eugene Oregon 97402 Approved Date <br /> Phone:(541)682-4896 <br /> Fax: (5411682-4879 ❑Applicant notified Date <br /> Application cannot be modified in any manner. Kanner aPplicanon 1-orm MUM November 1 2011 <br />
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