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2. *Please note :  Submitting this application does not guarantee approval. Before proceeding with the intended work, the Street Commissioner must review this request. If the request is approved, they will respond with a signed approval document.

4. The "Work" :*

   1. Street Cut* (bond required)
   2. Street Access Cut
   3. Curb Cut
   4. Sidewalk Cut

   1. Trail Cut* (bond required)
   2. Driveway Access
   3. Other
6. Date Certificate of Insurance and Bond Received
   Date Certificate of Insurance and Bond Received

   * For Street and Trail Cuts, bring your Certificate of Insurance and Bond to the Street Department Office at 1205 South Wayne Street or Email to Tim Simpson.

8. The undersigned Applicant is the owner of the property where the Work is to be performed and submits this application for consent from the City of Bluffton, Indiana (“City”), to perform the above indicated Work within a City right of way or easement as required by Chapter 12.04 of the City’s Code. Applicant acknowledges receipt of a copy of Chapter 12.04.

   Applicant agrees to indemnify and hold harmless the City, its agents and employees, from and against any and all loss or expense, including costs and reasonable attorneys’ fees, resulting from, arising out of, or in consequence of the performance of the Work by Applicant, Applicant’s employees, agents or independent contractors. Applicant further agrees to name the City as a named insured on Applicant’s insurance policies required to be maintained by this Application and to provide proof thereof to the City in a form acceptable by the City.

   Applicant agrees to reimburse the City for the cost of repair and/or restoration to original condition any City Street and Trail, and any electric, water or sewer conveyance damaged or excavated as a result of the Work of Applicant, Applicant’s employees, agents or independent contractors.

   Applicant agrees to comply with all applicable federal, state and local laws, codes, ordinances, rules and regulations in performance of the Work, including the Americans with Disabilities Act. Applicant has read and understands the Policy printed on the reverse side of this Application and agrees to comply with the Policy.

10. Date Application Submitted*
    Date Application Submitted
12. Date Work to Begin*
    Date Work to Begin
13. Estimated Date Work to be Completed*
    Estimated Date Work to be Completed
15. Location of Proposed Work*
17. Name of Applicant / Contractor*
19. Contact Phone Number*
20. Applicant Email*
22. Electronic Signature of Applicant / Contractor*
24. Information Consent*

    1. I consent to the City of Bluffton, Indiana storing my submitted information so they can respond to my inquiry.

26. *Reminder :  Submitting this application does not guarantee approval. The Street Commissioner will review the application and respond in a timely manner.

    If you have any additional questions, you may contact Tim Simpson at 260-824-0714.

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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field