|
S
<br /> CITY S1TEalh059
<br /> 1820 97402
<br /> EWE 5:41 2-02
<br /> Phone Order 7ermit fees MUST be included when the application is submitted:
<br /> faxed in if using a credit card. aX 682-48.12)
<br /> Fees are non-refundable
<br /> xxxxxxxxx 4121 Entry Meti�oa;Manual Amount o,yy��ISA Cash. ::)Check
<br /> '(/
<br /> 11% 37.AS $35.00 _ . _
<br /> 'Total: `$
<br /> NAME ON CARD dose Cruz ore ilcina
<br /> 09;09:?1 $ 2.45
<br /> 011M p.tode; 1�4% Expiration date_
<br /> . Inv t ,;;,,,y,a,!�l $37.45
<br /> 1:Online
<br /> C1 at e;lqj ossa p 3e is responsible for following all specifications established by the City for
<br /> the specifications is attached to this application form and is available at
<br /> Ci15toyet' Coo re to follow specifications may void City's approval of banner application.
<br /> THS You!
<br /> ` . -ase of emergency removal or failure to remove the banner(s) at the
<br /> _ contact the organization (permittee) and/or the permittee's listed installer. If the
<br /> X------------------ --------'--- my banner(s), the applicant will be required to cover the City's removal and
<br /> !lar chant Cony
<br /> THAW YOU!
<br /> ttion requirements: The organization named in this application, hereafter
<br /> mnants and agrees to defend, indemnify and hold harmless the City of Eugene,
<br /> rrom 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 $500,000 combined single limit per occurrence, for bodily injury, personal injury and property
<br /> damage. Such policy shall contain a contractual liability endorsement to cover Permittee's indemnification
<br /> obligations under this contract. The policy also shall contain an endorsement naming the City of Eugene as
<br /> an additional insured, in a form satisfactory to City. Proof of such insurance is required by the City
<br /> when the application is submitted. -'A
<br /> diV se�_,nki `.a qSay4 -ft
<br /> 6.
<br /> •
<br /> Sign the application (signature indicates you area Proof of sura ace pro id R , ','•e".',:.;4''3/''' .04
<br /> representative of the requesting organization):
<br /> I have ,-../• an. . •ree to the terms and conditions detailed under section #5.
<br /> Signatur- '0,,..1Date 1/107(81
<br /> 0
<br /> Titl- • sos' ion in organization Direc--or
<br /> 7. Incomplete Applications will not be processed and will be returned to applicant.
<br /> 8. __ 3 y C.w,::4 ri
<br /> Return application to: * r . .'e e, t i,j�,o,,,,w c ,..!,4 R X
<br /> Public Works Maintenance '�tJ� � 4 g 1 ,4 q"• - .a , "4" g','
<br /> r '1.f UGENE *7 ? Vik e
<br /> Atte:Banner Program i`��t .. �f ,°l
<br /> 1820 Roosevelt Blvd. �} 3F •Kit'
<br /> � �r �_Y > � ,�:,rS r' ti ti''KS�. �e... •i Hyl
<br /> Eugene Oregon 97402 {Appr¢vei :' ,, �7,.,..4.•!:z:-.','1$''.- f
<br /> Phone: (541)682-4896
<br /> Fax:(5411682-4879 Y 0 Applicant notified Date
<br /> Application cannot be modified in any manner. .. Banner application Form/PWMA'ovember 17,2011 1
<br />
|