Attachment: Civil Work Permit Application and Permit Form City of Gustavus, Alaska
Resolution CY19-05
Page 1 of 1
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 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________
