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Application Form for Dumpster Permit
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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
*
* indicates required fields.
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