CITY OF BLUFFTON

WASTE CONTAINER PERMIT REQUEST

(Fax (260.824.6080) or drop off to the Mayor's Office, 128 East Market Street)

I am requesting permission to place a waste container at:

(location)_____________________________________________________

from ____________________ until ________________________

for the purpose of:______________________________________________

I agree to place lights on or around the waste container for public safety and agree that I will not allow debris to accumulate around the waste container.

I further agree that on behalf of myself, my executors, administrators, heirs and next of kin, or if I am making this request on behalf of a business or corporation, its officers, directors, and stockholders, and any successors and assigns of the aforementioned, I HEREBY WAIVE, RELEASE AND DISCHARGE from any and all claims or liabilities for death, personal injury, property damage, theft or damages of any kind, which arise out of my use and/or placement of the waste container at the above described location, the City of Bluffton, the Mayor of Bluffton, the Common Council of the City of Bluffton, and any agents, successors, assigns or employees of any of the foregoing. I HEREBY AGREE NOT TO SUE any of the persons or entities mentioned above for any of the claims or liabilities that I have waived, released or discharged herein. I HEREBY AGREE TO INDEMNIFY AND HOLD HARMLESS any person or entity mentioned above from any claims made or liabilities assessed against them as the result of my use and/or placement of the dumpster.

I HEREBY AFFIRM THAT I AM EIGHTEEN (18) YEARS OF AGE OR OLDER AND AM AUTHORIZED TO EXECUTE THIS PERMIT REQUEST, AND THAT I HAVE READ THIS DOCUMENT, AND I UNDERSTAND ITS CONTENTS.

Printed name:________________________ Signature: ___________________________

On behalf of (group or organization, if any):_____________________________________

Telephone number:_______________________

Request approved/denied this ____ day of __________________________, 20__.

_____________________

Mayor