Department of Public Works
1855 Joliet Road Valparaiso, IN 46385
219-462-4612 www.valpo.us/pw

NAME OF THE PROPERTY OWNER*

ADDRESS OF PROPERTY OWNER*

PHONE NUMBER OF PROPERTY OWNER*

Email address

ADDRESS FOR DUMPSTER*

DUMPSTER WILL BE DELIVERED ON DATE*

DUMPSTER WILL BE REMOVED BY DATE*

DUMPSTER OR TRUCK WILL BE ACCESSING PLACEMENT ACROSS*

DRIVEWAY PARKWAY SIDEWALK

OTHER NONE

LOCATION OF DUMPSTER*

IN ALLEY ON PARKWAY ON PRIVATE PROPERTY

IN ROADWAY OTHER

NAME OF CONTRACTOR*

ADDRESS OF CONTRACTOR*

PHONE NUMBER OF CONTRACTOR*

NAME OF WASTE HAULER*

ADDRESS OF WASTE HAULER*

PHONE NUMBER OF WASTE HAULER*

CERTIFICATE OF INSURANCE ATTACHED*

YES

NO

CERTIFICATE OF LIABILITY INSURANCE

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PICTURE OF THE LOCATION THE DUMPSTER WILL BE PLACED

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Conditions for Permit Approval

Any placing of a dumpster on the street or right of way will require a permit obtained through the City of Valparaiso – Street Department.*

I agree

I do not agree

Permit must be returned a minimum of forty-eight (48) hours prior to dumpster delivery.*

I agree

I do not agree

Dumpster must be set back away from intersections a minimum of fifty (50) feet.*

I agree

I do not agree

Dumpster position must not block sidewalks, mailboxes or driveways.*

I agree

I do not agree

The refuse company shall mark dumpster with reflective tape or barricades on all sides exposed to street.*

I agree

I do not agree

No blocking of public roadway or alley without the Board of Public Works & Safety’s approval.*

I agree

I do not agree

The refuse company must have Certificate of liability insurance on file with Department of Public Works listing The City of Valparaiso as co-insured with liability limits determined by the Director of Public Works.*

I agree

I do not agree

The City of Valparaiso will not repair any damage to a public way as a result of the dumpster or delivery truck. This work will be the responsibility of the person(s) signing for this permit.*

I agree

I do not agree

I understand that this is a permit application, and Public Works will be in contact with me
for approval or denial of permit application.*

I agree

I do not agree

SIGNATURE*

DATE*