2. 
3. Row Application Form
5. Applicants Name:*
   Business Name/ Applicants Name
6. Phone:*
7. Email:
9. Street*
10. City*
11. State*
12. Zip Code*
14. Type of Closure:*

    1. Sidwalk
    2. Street

    1. Alley
    2. Parking Space(s)

    1. Other (explain below)
16. If Other please provide additional information in space provided.
18. Location of Closure:*
19. Additional Location Information: (attach maps)
21. Date of Closure:*
    Date of Closure: Start Date

    Date of Closure: Start Time

    —

    Date of Closure: End Date

    Date of Closure: End Time
23. Reason for Closure:*
25. Insurance*

    If applicable do you or your contractor (whoever is doing the work on the public ROW) have a valid proof of liability insurance in a minimum amount of $1,000,000 with the City named as additionally insured on file with the City? (If no you will need to have proof of insurance on file before the permit will be issued.)

    1. Yes

    1. No
27. Proof of Insurance *
29. Iowa ONE Call

    If you are digging, have you notified all utilities by calling Iowa One Call (800-292-8989) at least 48 hours before any digging?

    1. Yes

    1. No
31. Filing of this ROW Closure Application does not indicate or guarantee that the City of Storm Lake will approve this application. Application for ROW Closure is required at least five (5) days in advance of any closure.
33. Upon receipt of the completed application, certificate of liability insurance, and ROW Closure fee the City of Storm Lake will review the application and approve or deny the application. If approved the City of Storm Lake will issue a press release for the permit; however, this does not relieve the permit holder from notifying the adjacent and affected property owners of the closure.
35. Finally, if requested the City of Storm Lake will provide appropriate barricades and cones for the project which will have to be returned to the City of Storm Lake at the end of the closure. Failure to return the barricades and cones or any barricades or cones that are returned damaged will be subject to a replacement fee of $100 per barricade and $50 per cone.
37. By signing this application I agree to the terms and conditions of the City of Storm Lake ROW Closure Application and Permit.
39. Signature*
40. Date*
    Date
42. City of Storm Lake Building Official ~ 620 Erie Street ~ Storm Lake, IA 50588 ~ 712-732-8002
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field