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2. 

4. ♦ NOTE ♦ The dumpster is to be placed on private property only.
   It may not be placed on any street, parkway, apron or sidewalk.

6. Property Owner First Name:*
7. Property Owner Last Name:*
9. Property Owner Address 1:*
10. Property Owner Address 2:
12. Property Owner City:*
13. Property Owner State:
14. Property Owner Zip:
16. Property Owner Phone Number #1:*
17. Property Owner Phone Number #2:
21. Dumpster Site Address 1:*
22. E-Mail:

    Preferred method of sending you the permit.

26. Do you have a Contractor/Company?*

    1. Yes
    2. No
28. Contractor/Company Name:
29. Contractor/Company Phone:
31. Contact Name:
32. Contact Phone/Cell Number:
34. Company Address 1:
35. Company Address 2:
37. Company City:
38. Company State:
39. Company Zip:
43. Dumpster Company:*
44. Dumpster Company Phone:
46. Dumpster Company Address 1:
47. Dumpster Company Address 2:
49. Dumpster Company City:
50. Company State:
51. Company Zip:
55. Date of Dumpster Arrival:*
    Date of Dumpster Arrival: Start Date

    —

    Date of Dumpster Arrival: End Date

    A two week period is the maximum permit time.

56. Property Type:*

    1. Residential
    2. Commercial
58. Reason for Temporary Dumpster:

    1. Demolition
    2. Fire Repair
    3. General Exterior Clean-up

    1. General Interior Clean-up
    2. New Construction
    3. Remodel

    1. Roofing
    2. Siding/Gutters

    Please check all applicable boxes.

60. If Other Reason, Explain Below:

62. AGREEMENT:  By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

    Electronic Signature:

64. I hereby declare that all of the above information given is true to the best of my knowledge and belief.
    I agree to comply with all City and State Codes, ordinances and laws now in force and any others that may be enacted during the duration of requested permit.

66. Please type your First and Last Name:*
67. Date:*
    Date:
69. Legal Signature:*

    1. I Understand

    I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document.

Leave This Blank:


74. 1. Receive an email copy of this form.
75. Email address

    This field is not part of the form submission.

76. Submit

* indicates a required field