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,-1b-'is 'I S:'G 1 r KUP1- (ASA of Lane t;ounty 54 I yt54 14U 1 <br /> I-IZI ruUud/ r-Z b <br /> / <br /> (04 -L00- <br /> 4. Payment of banner permit fees MUST be included when the application Bisse ubnonmi teddeb/e <br /> (Banner applications can be faxed in If using a credit card.Fax 682.4&70 <br /> Description of fee Amount a Cash a Check <br /> • avISA UMC <br /> Basic charge $35.00 NAME ON CARD Micle Pound <br /> Administrative fee (7%) $ 2.45 Expiration date 03121 <br /> Total (pay this amount) $37.45 <br /> DJ. Conditions of Approval: <br /> Banner specifications: Permittee is responsible for following all specifications established by the City for <br /> banners. Information regarding the specifications is attached to this application form and is available at <br /> Public Works Maintenance. Failure to follow specifications may void City's approval of banner application. <br /> Emergency removal: In the case of emergency removal or failure to remove the banner(s) at the <br /> schedled tion <br /> nd/or the <br /> City sur qui ed to contact <br /> will bearequired toermittee's cover thelsted installer. f <br /> City's the <br /> removal and <br /> r <br /> storage costs. <br /> Insurance 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 /> am y and all costs, g ademands, sults, <br /> or actions, <br /> ltand recoveries for or on account of <br /> Its agents, servants or volunteers, and <br /> damage orm injury,sincluding ,death, tproperty p <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 costa for damage <br /> facilities <br /> any ror equip ley nt f resultting from <br /> on the <br /> installation or display of the described banner. City does notassume <br /> f <br /> facilities or equipment used. <br /> Permittee shall maintain a commercial general and auto liability insurance policy with ancoverage of ot <br /> less than $500,000 combined single limit per occurrence, for bodily Injury, personalinjury property <br /> damage. Such policy shall cotain 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. -,1��,"'0 9b1 n • <br /> ....%irk, :9v4;..' s. J,. <br /> Atfajd .1' <br /> 6. Sign the application (signature indicates you area � �+, . <br /> representative of the requesting organization): <br /> I have read and agree to the terms and conditions detailed under section#5. <br /> ��,Qq � �� Date t,i2a• <br /> r�a <br /> Signature /AI tit. _ 44 <br /> Title or position in organization Events Coordinator <br /> 7. Intern•fete A. •lications will not be •rocessed and will be returned to a• •licant. -v r ` <br /> x , <br /> �, <br /> 8. Return application o: i�� �.• �{ 3�Sf� =f^j�y �+S- <br /> Public Works Maintenance 4'�q,st ,,,:* ` \!Aunt < '" .f ;,,od- Tj .• '`y:< �k .v< a�+. <br /> Attn:Banner Program 4 �A "a{ .4%w\ 4 p <br /> 1820 Roosevelt Blvd. �"�� + • ' �•�,�•' ~s � ''•' % i� y...: ,-,4.4H''' <br /> a <br /> Eugene Oregon 97402 f s'��" a^ p 5' . N 6r� <br /> Phone: (541)682-4896et r� Jr gtQ`,t ` <br /> Fax: 15411682-4879 �-' <br /> Application cannot be modified in any manner. <br /> Banner appliratlonform/PWM November 17,1011 <br />