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4. Payment of banner permit fees MUST be Included when the application is submitted: <br /> (Banner applications can be faxed in if using a credit card. Fax 682-4879) Fees are non-refundable <br /> Description of fee Amount Cash Check <br /> XVISA MC <br /> Basic charge $35.00 NAME ON CARD JOS( (rut <br /> Administrative fee (7%) $ 2.45 Expiration date <br /> Total (pay this amount) $37.45 <br /> 5. 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 /> scheduled time, the City will contact the organization (permittee) and/or the permittee's listed installer. If the <br /> City is required to remove any banner(s), the applicant will be required to cover the City's removal and <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 /> 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 , s <br /> 6. Sign the application (signature indicates you are a Proof of insurance provided: 0 Yes O No ,„ <br /> representative of the requesting organization): <br /> I have re d and agree to the terms and conditions detailed under section #5. <br /> Signature .rC! ildr�_ Date iii/11 <br /> Title or position in organization /455j54Ar1+ Diced-6.r <br /> 7. Incomplete Applications will not be processed and will be returned to applicant. <br /> 8. Return application to: <br /> Public Works Maintenance 1 (E <br /> Atm: Banner Program • city Use Only <br /> 1820 Roosevelt Blvd. <br /> Eugene Oregon 97402 Approved Date_ <br /> Phone: (541)6824896 0 Applicant notified Date <br /> Fax: (5411682-4879 <br /> application cannot be modified in any manner. Banner application Form/PW.41 November 17,2011 <br />