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Application - Dumpster Permit

  1. 1. Applicant Information
  2. Who is applying?*
  3. 2. Dumpster Provider Information
  4. 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.
  5. 3. Dumpster Location Information
  6. Please provide details on where the dumpster will be placed.
  7. 4. Contact Information & Request Details
  8. Do you have a building permit?*
  9. This is the number in the upper right corner of the yellow placard or the number in the lower left of your permit.
  10. Must show location and dimensions of the dumpster.
  11. Are you the property owner?*
    If you are not the property owner you must provide proof of owner's authorization.
  12. If you are not the property owner please attach proof of owner's authorization here.
  13. Electronic Signature & Hold Harmless Agreeement
  14. 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.
  15. 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).
  16. Leave This Blank:

  17. This field is not part of the form submission.