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Street, City, State, Zip Code
By my signature below I agree that I will call Iowa One Call at 1-800-292-8989 prior to any digging activities related to this project. I also
agree that the information provided above is correct to the best of my knowledge. I understand that street cuts and curb cuts can only be
made by the City of Storm Lake and that I may be charged a fee for this service which must be paid prior to any work being done by the
City. I also understand that all repairs to the street cuts and curbs must be done in accordance with City specifications by either the City of
Storm Lake or a qualified contractor. Should I elect to use grinding as an alternative to a curb cut I agree that all grinding activity must be
completed by a city approved contractor. I agree to make myself available for inspections as required by the City and to call for
inspections at least 24 hours in advance of when they are needed.
THIS PERMIT AUTHORIZES CONSTRUCTION OF IMPROVEMENTS SPECIFIED.
By signing above, the applicant hereby agrees, in consideration of the issuance of this permit, to assume responsibility for and to hold the City
harmless in regard to any and all claims of injury or damage arising from the acts or omissions of the applicant or his/her agents while acting
under the authority of this permit. The applicant further agrees to comply with the provisions of the Code of the City of Storm Lake, Iowa and
29 CFR Part 1926.650, 651 and 652 as adopted by the Iowa Division of Labor.
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