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Standard Use and S e'dal Permit Application City of Eugene The completed application form, required attachments, non - refundable Public Works Blvd. Bl Roosevelt permit fee, and any other fees must be submitted to Public Works at 1820 Eugene, 1820 Roose se elt Bl Roosevelt Blvd. A separate check for the security deposit is required. (541) 682 -4800 • Applications will be processed in order of receipt and will be approved ,j or denied with 14 days of receipt unless the Executive Director or designee extends the processing period by an additional 14 days by written notice to the applicant. AUG 5 2005 • If, after submission of an application but before a decision is rendered, the applicant submits additiona application materials, a decision will be rendered' 14 days of receipt of the additional materials. • Permit decisions will be mailed to the applicant at the address below. Standard Use 0 Special Use 0 1. Name of event: ,, JI C t L IT Vo-- 2. Requested park, open space or park facility (he`sp�ecific 3. Date: Time: from to Estimated Attendance: 1 U - 300 4. Event Sponsors: .. Vv. ct �A J C f ` M Representative Name: 1LK, 1 V`, f ) 0rU Phone: 0 4 .� Address: City/Zip V �� -`i 74 t3' P� �. E-Mail Address: VV ✓ 110rO U L . 64 S. Will this event: (If the answer is yes to any of the questions below, you must obtain a Special Use Permit.) A. Have a controlled admission (i.e., require an admission fee) ?X YES O NO B. Require the erection of canopies tents, booths, or stages? 0 YES :ENO C. Be advertised as a public event ?YLYES 0 NO D. Amplify sound for more than two hours? 0 YES ANO E. Use a park or open space facility as a stegin site for a public event that exceeds the capacity of the rental facility? 0 YES NO 6. Will food be served, sold, or given away? 0 YES X NO (If yes, you must provide the City with a copy of a temporary restaurant license from Lane County Environmental Health at least 20 days prior to the date of the event.) 7. Will alcoholic beverages be sold or served free of charge? 0 YES �*O (If yes, you must comply with the applicable insurance and OLCC license requirements set forth in Administrative Order 58- 03 -24 -F, Rule 1.004(3).) 8. Will goods or services be sold? 0 YES " Y NO (If yes, you must comply with Administrative Rule l .004(5).) 9. Will equipment, booth, garbage boxes, portable restrooms, or a stage be brought to the site? 0 YES JkNO (If yes, this application must be accompanied by a site plan for the park/open space.) )0. Will amplified sound be used for more than 2 hours? 0 YES 6(NO (If yes, this application must be accompanied by a schedule of entertainment.) 11. Will the park or open space be used to hold a mee/walk/bike event? O YES ONO (If yes, this application must be accompanied by a route map for the park and streets.) 12: Is attendance anticipated to exceed 500 people? D YES J�6NO (If yes, this application must be accompanied by a certificate of insurance that complies with Administrative OrderNo. 58- 03 -24 -F, Rule 1.0.04(2)(a). Also, if yes, you must provide security and traffic control personnel for the event in compliance with Administrative Order No. 58- 03 -24-F, Rule 1.004(6) and this application must be accompanied by a traffic control plan.) 13. _All "`applicable fees must be submitted with this - application. Permit fees are non - refundable: `If an event is 1 canceled, facility rental fees are refundable in the manner prescribed by Administrative Order of the City Manager. 0 Standard Park'Permit Fee: $ o Special Event Permit Fee: $ 0 Facility User Fee: $ 4 Security Deposit (Separate Check): $ O Vehicle Permit Fee(s): $ . ❑ Other I, V1 k U L Vo& 1 69" k:that am the permit applicant. I certify that I am an authorized representative of the above organization (if any). I ` the above statements are true to the best of my knowledge. I have received a copy of Administrative Order No. 58- 03 -24 -F, Park and Open Space Rules, and I and/or the organization I represent agree to be bound by all applicable regulations. I and/or the organization I represent understand that any violation of any of these .agreements will result in forfeiture of deposit, immediate termination of event, and jeopardize future use of City facilities. I and/or the organization I represent agree to indemnify, defend, and hold harmless the City of Eugene, its officials, agents and employees from and against any and all claims of injury to property or persons that may arise as a result of any activity occurring at the event for which I seek this permit. I and/or the organization I represent agree to pay all costs of damage and/or vandalism to the k or facilities used.in relation to the event for which I seek this permit. 8 v5 t44 L f ON V1 L Signature Date Print Name