CERTIFICATE OF INSURANCE REQUIREMENT
Permit Process
The applicant shall furnish the City of Lynchburg a Certificate of Insurance which reflects a
general liability limit of at least $1,000,000 names the City of Lynchburg, its agents, and its
employees as additional insured. The certificate must be approved by the Risk
Management Department (455-3815). As a provision of this permit the permittee shall,
upon expiration of the permit, return the public right-of-way being used to be returned to
its existing condition at the time of permit issuance. Should that not be accomplished
within two (2) days of expiration, completion, revocation, or termination of the permitted
activity, the City will perform the necessary work and the permittee agrees to reimburse
the City for the associated costs.
By signing below, the permittee agrees to abide by the fees and conditions pertaining to the
specific type of use being permitted, which are set forth in the attached documents.
The undersigned hereby agrees to abide by all City regulations controlling permitted use of
the right-of-way, and further acknowledges that violation of permit conditions and or City
Code will result in the revocation of this permit and the violator being charged with a
fourth degree misdemeanor under the Virginia Statutes.
Applicant’s Name:
Applicant’s Address (Street, City, State, Zip:
Applicant’s Signature:
Note: If you already have the certificate of insurance in digital format, you may attach it with
this document and return it to Public Works Engineering, attn.: Patricia Martin, 900 Church
Street, Lynchburg, VA 24504..
