Council Bluffs Water Works Hydrant Meter Application/Permit Form

Permit Fee______Amount Deposited______

Date of Issue______Date of Expiration______

Name of Applicant/Company______

Mailing Address______

Name and Telephone Number of Contact Person______

Purpose or Use______

Location of Work______

Meter Size Requested ______Estimated Usage Amount______

Certificate of Insurance Received: Yes or No

Terms and Conditions

By Ordinance, the City Council of the City of Council Bluffs, Iowa, has authorized the Board of Water Works Trustees of the City of Council Bluffs, Iowa (the “Board”) to adopt certain rules and regulations governing the issuance of permits to persons, (other than employees of said City while performing services in the course of their employment), for the purpose of permitting such persons to manipulate, operate or use any of the appliances, equipment or parts of a public fire hydrant now or hereafter installed by the Water Works of the City of Council Bluffs, Iowa (the “Water Works”).

Pursuant to the authority granted by said Ordinance Number 3570, the Board has delegated to the Secretary of the Board (the “Secretary”) authority to issue such permits under the following terms and conditions:

1. The Applicant agrees to abide by the rules and regulations of the Board now in force and those hereafter adopted from time to time pertaining to the manipulation, operation or use of any of the appliances, equipment or parts of a public fire hydrant.

2. The Applicant agrees that prior to issuance of a hydrant meter permit (the “Permit”), Applicant shall file with the Secretary, or the Secretary’s delegate, a Certificate of Liability Insurance (ACORD Form 25 or equivalent) verifying the existence of the following coverage: Commercial General Liability (or an equivalent form) providing insurance to cover Bodily Injury, Property Damage, Personal Injury and Advertising Injury with limits of at least $1,000,000 per occurrence and $1,000,000 annual aggregate. This policy shall name the Applicant as the Insured and shall name the Water Works and the Board as Additional Insureds. The Board shall be shown as the Certificate Holder and there shall be 30 days’ prior written notice of cancellation given to the Board by the insurance company. Applicant hereby waives subrogation rights under this policy against the Board. The insurance company providing coverage under this Certificate shall carry a financial rating as assigned by A.M. Best of at least A-.

D:\Docs\2017-12-17\09e343a4af5b427fdac8b991193c25d9.doc 2/21/2007 6:58 PM 3. The Applicant must make application for a specific use of the fire hydrant(s) at a specific location(s) for the specific purpose expressed on this application which shall limit the authority of operation.

4. The Applicant agrees to pay for the water used from fire hydrant(s) permitted hereunder at the rates in force at the time this application is submitted to the Secretary.

5. The Applicant agrees to deposit with the Water Works such funds as are required by the Board. Such deposit, less service charges, charges for water used and other costs and expenses incurred and accrued as a result of the manipulation, operation or use of any of the appliances, equipment or parts of a public fire hydrant, shall be refunded to the Applicant on return of all appliances, equipment and parts that were issued as a result of this application in good working order.

6. The Applicant agrees to keep the permit issued as a result of this application in Applicant’s possession at all times while manipulating, when operating or using any of the appliances, equipment or parts of a public fire hydrant authorized by said permit, for inspection by authorized Water Works personnel in order to verify that proper authority has been granted Applicant for such purpose.

7. The Applicant agrees that the permit or application does not entitle Applicant to manipulate, operate or use any of the appliances, equipment or parts of any public fire hydrant for the purpose of fire protection.

8. The Applicant acknowledges that any violation of the rules and regulations established by the Board pertaining to the manipulation, operation or use of any of the appliances, equipment of parts of any public fire hydrant now or hereafter installed by the Water Works, constitutes a misdemeanor and the violator may be prosecuted by due process.

This application is signed with the specific acknowledgement that the terms and conditions hereof and the rates to be charged hereunder are fully accepted and are the only conditions upon which service is supplied to the Applicant through a public fire hydrant.

Applicant’s Signature Title

Approved by Council Bluffs Water Works

Signature of Employee Title

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