Application - Dumpster Permit

2. Dumpster Permit Guidelines
   Click here to review dumpster permit guidelines.

4. 1. Applicant Information

6. Applicant First Name*

7. Applicant Last Name*

9. Address1*

11. Address2

13. City*

14. State*

15. Zip*

17. Applicant Email *

18. Applicant Phone Number*

20. Who is applying?*

    1. Owner
    2. Contractor
    3. Other

22. Please provide details.

24. 2. Dumpster Provider Information

26. Dumpster Company Name*

28. Address1*

30. Address2

32. City*

33. State*

34. Zip*

36. Dumpster Company Email*

37. Dumpster Company Phone Number*

39. Certificate of Insurance

    We must have a current and valid certificate of insurance on file listing the City of Lafayette as the certificate holder. No permits will be issued without the insurance on file.

41. 3. Dumpster Location Information

43. Address1*

45. Dumpster Location*

    Please provide details on where the dumpster will be placed.

47. Requested Placement and Removal Dates*
    Requested Placement and Removal Dates Start Date

    —

    Requested Placement and Removal Dates End Date

49. 4. Contact Information & Request Details

51. Onsite Contact First Name*

52. Onsite Contact Last Name*

54. Onsite Contact Email*

55. Onsite Contact Phone Number*

57. Do you have a building permit?*

    1. Yes
    2. No

59. What is your Project Number?

    This is the number in the upper right corner of the yellow placard or the number in the lower left of your permit.

61. Please describe the work being done and the reason for requesting a dumpster permit.*

63. Site Plan*

    Must show location and dimensions of the dumpster.

65. Owner First Name*

66. Owner Last Name*

68. Are you the property owner?*

    If you are not the property owner you must provide proof of owner's authorization.

    1. Yes, I am the property owner
    2. No, I am not the property owner
70. Owner's Authorization

    If you are not the property owner please attach proof of owner's authorization here.

71. Owner's Authorization
    Click here to download an owner's authorization form.

73. Electronic Signature & Hold Harmless Agreeement

75. Hold Harmless Agreement*

    The City of Lafayette will be held harmless of any and all liability arising from the placement of a dumpster on the street at the requested location.

    1. I Agree
    2. I do not Agree
77. Signature*

    I certify that I am the owner, or legal agent of the owner, of the real estate subject to this application or I have been authorized by the owner, or legal agent of the owner, to submit this application (separate Letter of Consent required). By checking "I Agree" you are acknowledging your agreement with the terms stated in this document and further certifying that checking the box counts as an electronic signature. Your electronic signature is considered legally binding the same as signing your physical signature by hand (IC 26-2-8).

    1. I Agree
    2. I do not Agree
Leave This Blank:


79. 1. Receive an email copy of this form.
80. Email address

    This field is not part of the form submission.

81. Submit

* indicates a required field