Office Use Only

Village of Lakemoor Dumpster/Roll-Off/Storage Pod Permit Application

☐ Approved ☐ Not Approved Permit No. ______________________ Building Permit No. _____________ Date Issued ___________________ Approved by___________________ Fee: $________________________

SECTION I – GENERAL INFORMATION

Permit Applying For: ☐ Dumpster ☐ Roll-Off Container ☐ Storage Pod Placement of Dumpster/Container/Storage Pod: ☐ Private Property

Duration: _______ Days Date: _________

☐ Village Right-of-Way/Street

_______________________________ _______________________________________________ Dumpster Location(Address)

Dumpster/Roll-Off/Storage Pod Company

_____________________________________ Size of Dumpster/Container/Storage Pod

________________________________________________________ Company Contact Information

SECTION II – PROPERTY OWNER INFORMATION

_______________________________ _______________________________________________ Property Owner’s Name

Property/Owner’s Mailing Address

_____________________________________ Property Owner’s Phone /Cell #

________________________________________________________ Property/Owner’s E-mail Address

SECTION III – PROJECT DETAILS Have you applied for a building permit for this project?

☐ Yes ☐ No

_____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ SECTION IV – LIABABILTY WAIVER LIABABILTY WAIVER (TO BE SIGNED BY AUTHORIZED COMPANY REPRESENTATIVE OR HOME OWNER) If requesting permission to place a dumpster on the public right-of-way in the Village of Lakemoor in accordance with Village Ordinance #15-O- 42. For consideration of such permission, I hereby fully release and discharge the Village of Lakemoor, its officers, agents and employees from any and all claims from injuries, including death, damages or losses, which may arise or which may be alleged to have arisen out of, or in connection with, the placement of said dumpster. I further agree to indemnify and hold harmless and defend the Village of Lakemoor, its officers, agents and employees, from any and all claims resulting from injuries, including death, damages or losses, including, but not limited to the general public, which may arise or which may be alleged to have arisen out of, or in connection with the placement of said dumpster. A maximum of one dumpster, roll-off container, or temporary storage unit is permitted on any one lot at any time. Unless otherwise specified, any permit issued shall only be valid for a maximum of sixty (60) days. I further understand that I am responsible for securing all permits from the Village of Lakemoor and any other jurisdictional permits and/or approvals for any work being performed on the property. (This also applies to Home Owners Associations (HOA)) ________________________________________________________________________________________________________________________ Applicant Signature Applicant Printed Name Date Applicant is:

☐ Property Owner

☐ General Contractor

☐ Tenant

☐ Other ________________________________________________