12/10/2020
City of Gustavus
Civil Work Permit Application and Permit Form
Submit to Gustavus City Hall, in person or to PO Box 1, Gustavus, AK 99826, or
email to administrator@gustavus-ak.gov
Requesting entity: __________________________________
Contact person: ____________________________________
Address: ___________________________________________
Phone(s): ___________________________________________
Email: ______________________________________________
Permit Type: 1) Routine_____ 2) Emergency _______ 3) Blanket_________
Work location(s):
_____________________________________________________________________________________________
Period work will occur (dates and times):______________________________________________________
______________________________________________________________________________________________
Work description (attach additional pages if needed. Include any design documents, equipment
specifications, or other details needed to meet the intent of the permit. If emergency, describe):
______________________________________________________________________________________________
Equipment to be used on site:
_____________________________________________________________________________________________
Utilities location provisions:
_____________________________________________________________________________________________
Traffic Safety and flow provisions: Any residents affected by the permitted work must be notified 24
hours prior to commencement of activities. Coordination with any resident that may have
egress/ingress blocked or impaired is mandatory to ensure availability for emergency vehicles or
use by the occupant(s) is provided if necessary.
_____________________________________________________________________________________________
Site restoration provisions:
_____________________________________________________________________________________________
Other provisions for compliance with permit requirements:
_____________________________________________________________________________________________
Applicant Attests: In signing this permit application I understand that I may not begin site civil
work until the City of Gustavus has issued me an approved civil work permit for the covered work.
I agree to comply with the terms of the permit including amendments required by the city
administrator. I understand that work in the city maintained road/easement is subject to road
work done in the future and that any costs incurred to me including relocation of equipment, loss of
service to customers, or repairs to the city roads will be at my own expense. I will notify the city
administrator in writing at the start and completion of the permitted work. I will notify the
administrator in writing in advance if there are any significant changes to the work plan that may
affect the terms of the permit.
Applicant Signed ______________________________ Date of application: ________________
For official Use Only:
Permit is Approved___ Not Approved___ City Administrator: __________Date________
Final inspection required Yes___ No___
Project is complete and accepted. City Administrator: _____________Date________
