Application/Permit for Placement of Dumpster: Contact Lieutenant Faranda Telephone 973-748-8400 x117 Facsimile 973-748-2595 Number ____________               Fee $50.00 Name: _____________________________________________________________ Address: ____________________________________________________________ Phone: ____________________ (Business)       ____________________ (Home) Reason Dumpster cannot be placed on private property: ________________________________________________________________________ Requested location of dumpster: ________________________________________________________________________ Placement Date: ________________     Date of Required Removal: ________________ This Permit is subject to revocation for any violation of Borough Ordinance pertaining to the placement of roll - off dumpsters, a copy of such Ordinance being attached hereto and made a part of this Permit. Prior to using this Permit, the permit-holder must supply to the Police Department of the Borough of Glen Ridge a copy of a CERTIFICATE OF INSURANCE for the location of the dumpster. If the holder of this Permit should need an extension hereof, the permit-holder must contact the Police Department of the Borough of Glen Ridge prior to the expiration date of the current permit. Should no requests be made prior to the expiration date and the dumpster remains on the street thereafter, a summons will be issued. By accepting this Permit, the holder hereof agrees to defend, indemnify, and hold harmless the Borough of Glen Ridge from any and all damages, costs, losses, claims, and expenses (including reasonable attorney fees), and any other liabilities, be they involving losses to persons or to property, which the Borough of Glen Ridge may become subject, arising out of or in connection with the placement and usage of the dumpster in the Borough of Glen Ridge, including without limitation, any Public Right of Way therein, by the undersigned, provided such loss is not occasioned by the sole negligence of the borough of Glen Ridge or any of its agents. CERTIFICATION The undersigned certifies that the above statements are true and agrees to comply with New Jersey State Statute 27:5I-1, concerning waste and refuse containers and the terms and conditions of the ordinance of the Borough of Glen Ridge attached to this permit. Date of Application: ______________     Signed: ______________________________ Date of Approval: ____________     Approval Signature: ________________________ Comments: ________________________________________________________________________ ________________________________________________________________________