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Vo kccivelhnf kl4nn4 soiivh A-srNNH@yowl city <br /> We mvst VS( A V0 rnhnnnj (Ad, ii <br /> 4. nnerr.:nt of banner permit fees MUST be included when the application <br /> are non-re undable /t"Vin's IT <br /> (Banner i pplications can be faxed In if using a credit card. Fax 682.4879) <br /> Descriptior of fee Amount Cash Checki ti OL1 V b`1 2 i 7r <br /> VISA MC p <br /> 7 At— <br /> Basic charg , $35.00 NAME ON CARD QaF ice e4 Dec.4.4 rr4 `rtu )e' 43 k1 <br /> Administrati e fee (7%) $ 2.45Q 0 A "D (t`1 inExpiration date <br /> Total (pay t its amount) $37.46 0:3/ tL C <br /> 5. Conditic ns of Approval: ed ity <br /> Banner spec Ificatlons: Permittee is responsible for following all specifications <br /> stablished sy thavailae <br /> for <br /> banners. Int )rmation regarding the specifications is attached to this application ofr banner application. <br /> Public Works Maintenance. Failure to follow specifications may void City's approval <br /> Emergency removal: In the case of emergency removal or failure to remove the banner(s) at the <br /> tion <br /> tee) <br /> nd/or the <br /> the <br /> City sulequu d toremove iany tbanner(s), the aapplicant mw l bear required toe cover thee's cIfsted installer. <br /> City City's removal and <br /> storage cost: <br /> Insurance a id indemnification requirements: The organization named in this application, hereafter <br /> referred to at Permittee, covenants and agrees to defend, indemnify <br /> esand and <br /> hold harmless <br /> forthe <br /> City oon of <br /> Eugene <br /> e, <br /> from any ant all costs, claims, demands, suits, actions, judgments, <br /> damage or in ury, including death, to property or person to Permittee, its agents, servants or volunteers, and <br /> to all membe s of the public, caused by or arising out of the installation or display of the described banner. <br /> Permittee ag ees to pay all replacement costs for damage to City facilities or equipment resulting from the <br /> installation oi display of the described banner. City does not assume any responsibility for the condition of <br /> facilities or et uipment used. <br /> Permittee sh• Ii maintain a commercial general and auto liability insurance policy with coverage of not <br /> less than $5 )0,000 combined single limit per occurrence, for bodily injury, personal Injury and property <br /> damage. Su:h policy shall contain a contractual liability endorsement to cover Permittee's indemnification <br /> obligations u der this contract. The policy also shall containan <br /> of endorsementsuoh nce amits the ng the Cuied ity of <br /> by Eugene <br /> ay <br /> an additional insured, in a form satisfactory to City. <br /> when the ap ilication is submitted. City Use Only <br /> 6. Sign he application (signature indicates you are a Proof of insurance provided:❑Yes ❑No <br /> repre: entative of the requesting organization): <br /> I havere greet the terms and conditions detailed under section#5. <br /> signature �� Date__ D2� (A 1 It�(p id C ,- <br /> Title or posi ion in organization /h�t(/'�Y-r V D VIVim/us �n <br /> 7. Income, ite Applications will not be processed and will be returned to applicant. <br /> 8. Return application to: AA <br /> Public Works Maintenance o GENE City Use Only <br /> Attn: F anner Program <br /> 1820 6 oosevelt Blvd. Approved Date <br /> Eugem Oregon 97402 <br /> Phone. (541)682.4896 ❑Applicant notified Date <br /> Fax:i` i11682-4879 <br /> .dpplica' on cannot be modified in any manner 1 I Raymer application Form/PIM November 17,2011 <br />