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2. First Name
3. Last Name*
5. Street Number*
6. Street Name*
7. Contact Number*
9. Email*
10. Anticipated Access Date(s) & Time of Day*
    Please indicate the date(s) and time of day for which you are requesting to access public property.
12. Location of Public Land You are Requesting to Access*
    Enter the name or a brief description of the public property you are requesting to cross.
13. Vehicular Access Requested?*

    1. Yes
    2. No

    Will a vehicle be crossing public land?
15. Purpose for Request*
    Please describe the reason for your request (e.g., vehicular access to remove large tree limbs) or the type of activity that will be conducted.
18. Acknowledgement*
    -- Select One --YesNo

    The applicant acknowledges that the City of Lafayette does not assume any liability for any acts or omissions of the applicant(s) or its agent(s) carrying out the activities specified above, and, to the extent allowed by law, the applicant hereby agrees to defend, indemnify and hold harmless the City of Lafayette, and its officers, agents and employees, from and against all liability, claims, demands, and expenses, including court costs and attorney fees, on account of any injury, loss, or damage, which arise out of or are in any manner connected with the above-described activities, except to the extent caused by the negligence of the City of Lafayette.
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25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field