Revised 3/29/2018
City of Portage
Street Use Permit Application
Street Use Permits: Chapter 66, Article V, Division 4
Application Date:______________ (Must be received 15 days prior to the event)
Application Fee: $25.00 Receipt No. ___________
Name or Organization: ______________________________________________________________
Contact Person: ______________________________________________________________
Address: ______________________________________________________________
Phone Number: ___________________________ Email: _____________________________
Event: ________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Date of Event: _________________________________________________________________________
Hours of Event: ________________________________________________________________________
Name of Street to Be Closed: ____________________________________________________________
From (Street Name): ____________________________________________________________
To (Street Name): ____________________________________________________________
Services Requested (i.e., barricades, trash containers) Note: If this event requires any city services, you
must also complete a Special Event Permit Application and submit it to the City at least 45 days prior to the
event. ________________________________________________________________________________
________________________________________________________________________________
Certificate of Insurance (attach to form):
Amount of Coverage_______________________ Insurance Company _____________________
The undersigned agrees to release, defend and hold the City of Portage and its employees and agents harmless against
all claims, liability, loss, damage or expense incurred buy the city on account of any injury to or death of any person or any
damage to property caused by or resulting for the activities for which the permit is granted.
__________________________________________ ________________
Signature Date
For Office Use Only
Reason for Denial
Chief of Police
Approval
Denial
City Clerk
Approval
Denial
Public Works
Approval
Denial
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome