CAPITOL SQUARE REVIEW AND ADVISORY BOARD REQUEST FOR WAIVER UNDER O.A.C.

128-04-02(I) This form is to be used by any person desiring to obtain a waiver of any provision set forth in Ohio Administrative Code 128-04-02. Rules may be waived for good cause shown, as provided in O.A.C. 128-4-02(I). PERSON REQUESTING WAIVER [completed by applicant]: NAME: STREET OR E-MAIL ADDRESS: PHONE NUMBER: PROVISION(S) OF RULE FOR WHICH WAIVER IS REQUESTED [completed by applicant]:

GOOD CAUSE FOR GRANTING OF WAIVER [completed by applicant]:

DATE FOR WHICH WAIVER IS REQUESTED [completed by applicant]:

CONDITIONS FOR GRANTING OF WAIVER: By requesting this waiver, the undersigned applicant agrees that: 1. The information provided on this application is truthful and complete; 2. The applicants use of the Capitol buildings and grounds with the benefit of such waiver: a. Does not interfere with the primary use of the capitol buildings or grounds, including but not limited to its use as a site of the legislative activities of the Ohio general assembly; offices of state elected officials; as a living museum of Ohios historical, artistic, and architectural heritage; and as a public park;
Page 1 of 3

b. Is appropriate to the legislative, historical, artistic, architectural and esthetic context of the capitol buildings or grounds; c. Does not unduly burden the managing authority by a use that includes but is not limited to one that requires excessive financial, staff, security, or equipment resources, or that unduly threatens the physical, historical, architectural, artistic, or esthetic condition of the capitol buildings or grounds, or unduly threatens the safety of the public or state employees; and d. Does not expose the state to the likelihood of unreasonable expenses and/or damages that cannot be recovered. 3. The applicant understands that this waiver does not constitute a permit to use any part of the Capitol building and grounds, and that the applicant must apply separately for a permit when Capitol Square Review and Advisory Board rules so require (see O.A.C. 128-0402(B)). 4. The applicant understands that this waiver applies only to the specific provision(s) of O.A.C. 128-04-02 identified on this application and that the applicant must abide by all other laws or rules governing use of the Capitol building and its grounds. 5. The Capitol Square Review and Advisory Board reserves the right to revoke this waiver at any time when, in the good faith judgment of the Board or its designee, the applicants use of the waiver is deemed to violate any part of O.A.C. 128-4-02(A)(1)-(4) or if applicants use of the waiver unduly interferes with the Boards ability to operate the Capitol building and grounds safely and effectively. If the Board elects to revoke this waiver, the Board will notify the applicant using any of the contact information provided on this form that the waiver is revoked. 6. This waiver is granted upon the express condition that the Capitol Square Review and Advisory Board, its agents and employees shall be free from all liabilities and claims for damages and/or suits for or by reason of any injury, or death to any person or damage to property of the applicant or third parties, from any cause or causes whatsoever while in or upon the Capitol building or grounds, or any part thereof, during the term of this waiver, relating in any way to applicants failure to follow the rule for which this waiver was granted, and the applicant hereby covenants and agrees to indemnify, defend, save and hold harmless the Capitol Square Review and Advisory Board, its agents and employees from all liabilities, charges, expenses and costs on account of or by reason of any such injuries, deaths, liabilities, claims, suits or losses however occurring or damages growing out of the same.

Page 2 of 3

APPLICANT: SIGNATURE: Date:

CAPITOL SQUARE REVIEW AND ADVISORY BOARD: This request for waiver of O.A.C. 128-04-02 [GRANTED] [DENIED*] (circle one). (identify provision) is

SIGNATURE: PRINT NAME:

Date:

If granted, this waiver is effective for the following date(s):

FROM:

TO:

* If denied, reason for denial explained below:

Page 3 of 3