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CITY Of EUGENE POS <br /> 1620 ROOSEVELT BLVD <br /> EUGENE, OR. 97402-4159 <br /> 541 682-4812 **Subject to the conditions and limitations of Article XI,Section 7 <br /> of the Oregon Constitution and other laws regulating liabilities <br /> Phone Order or monetary obligations of University,including the Oregon Tort <br /> Claims Act,ORS 30.260 through ORS 30.300 <br /> xxxxxxxxxxxx6922 banner permit fees MUST be included when the application is submitted: <br /> VISA Entry Method: Manual ,ns can be faxed in if using a credit card. Fax 682-4879) Fees are non-refundable <br /> Amount:$ 37.45 Amount Cash Check <br /> Tax: $ 0.00 VlsA$35.00 NAME ON CARD(fit" n Iy C_i- -CeS+i J4-1 <br /> Total: # 37.45 7%'l 2.45 <br /> Expiration date <br /> I <br /> Inv <br /> t:10 08:15;48 punt) $37.45 Iktme cr�,.� syl-3Yty— 13t'1 1", a. <br /> r atm-a4 c? J <br /> Inv #: 000004404 AP- :.ode: 036350 <br /> APPrvd: Online approval: <br /> AVS Code: ins: Permittee is responsible for following all specifications established by the City for <br /> CVV2 Code: NOT PROCESSED P n regarding the specifications is attached to this application form and is available at <br /> mance. Failure to follow specifications may void City's approval of banner application <br /> CU.A0 el e.N, <br /> ?;1: in the case of emergency removal or failure to remove the banners) at the <br /> THANK YDU. amity will contact the organization (permittee) and/or the permittee's listed installer. If the <br /> amove any banner(s), the applicant will be required to cover the City's removal and <br /> !kruhart COPY emnification requirements: The organization named in this application, hereafter <br /> THANK YOU! tee, covenants and agrees to defend, indemnify and hold harmless the City of Eugene, <br /> its, claims, demands, suits, actions, judgments, and recoveries for or on account of <br /> luding 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 /> ulJiigations 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 sucft 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. 0 Yes 0 No <br /> representative of the requesting organization): <br /> I have read and agree to the terms and conditions detailed under section#5. <br /> Signature_ V - "�"` _ Date I zfi/f <br /> Derek Dizney <br /> Title or position in organization Contracts Officer <br /> Purchasing and Contracting Services <br /> 7. Incomplete Applications will not be processed and will be returned to applicant. <br /> 8. Return application to: <br /> Public Works Maintenance Et;29 <br /> Attn: Banner Program City Use Only <br /> 1820 Roosevelt Blvd. <br /> Eugene Oregon 97402 Approved Date <br /> Phone:(541)682-4896 <br /> Fax:(541)682-4879 ❑Applicant notified Date <br /> Application cannot be modified in airy manner. Banner application Fonn PTV 11 November I?.2011 <br />