APPLICATION FOR
TEMPORARY STRUCTURE PERMIT
Complete all sections on both pages except for the two sections marked “For Office Use”.
Application Date_____________________________
PROJECT INFORMATION & LOCATION:
Project Type:
Structure Type:
□ Commercial, □ Multifamily, □ Residential Project Name:____________________________________
□ Existing Building, □ New Building, □ Non-Habitable, □ Temporary Structure
Project Address_______________________________________________________ Unit/Suite/Floor_________ Zip Code__________
Locator/
Subdivision or
Parcel No.____________________________ Building/Center Name ______________________________________ Lot No._______
□ Unincorporated County,
or Municipality______________________________________
Fire District______________________
Brief description of temporary structure construction/set-up scope of work:
OWNER/TENANT INFORMATION:
Property Owner_______________________________________________________________________________________
Last Name
First
Telephone
Fax
Email
Owner’s Address ______________________________________________________________________________________
Street Address
City
State
Zip Code
□
Tenant/Business Name ________________________________________________________________ Existing,
□ New*
*If a New Tenant/Business indicate the Previous Tenant/Business Use _________________________________________
ARCHITECT/ENGINEER INFORMATION:
Name & Address
Telephone
Fax
Email
If New Tenant/Business Indicate The Previous Tenant/Business Use _____________________________________
PRIMARY CONTACT INFORMATION IF OTHER THAN APPLICANT:
Name & Address
Telephone
Fax
Email
PERMIT NO.____________________________________
WORK DESCRIPTION:
APPLICANT CERTIFICATION & INFORMATION
I CERTIFY THAT I AM THE OWNER IN FEE OR AGENT AUTHORIZED TO APPLY FOR THIS PERMIT, THAT I HAVE AN AGREEMENT WITH THE OWNER/LESSEE TO PREFORM THIS WORK; AND THAT
I AM AUTHORIZED TO AND DO CONSENT TO ENTRY ONTO THE PREMISES BY ST. LOUIS COUNTY EMPLOYEES FOR INSPECTION OF WORK PERFORMED UNDER THIS PERMT. THE SCOPE OF
WORK INDICATED AND COST ESTIMATES ARE TRUE AND CORRECT.
IF A PARTIAL PERMIT IS BEING REQUESTED, I REQUEST AUTHORIZATION TO PROCEED WITH THE CONSTRUCTION INDICATED IN ORDER TO ALLOW CONSTRUCTION TO COMMENCE. I
ACKNOWLEDGE THAT IF AUTHORIZATION IS GIVEN THAT I WILL BE PROCEEDING AT MY OWN RISK WITHOUT ASSURANCE THAT A PERMIT FOR THE ENTIRE WORK OR STRUCTURE WILL BE
GRANTED. I AM RELEASING ALL LIABIITY, INDEMNIFYING AND HOLDING HARMLESS ST. LOUIS COUNTY, ITS OFFICERS, EMPLOYEES, AGENTS, AND ANY ASSIGNS FOR ANY EXPENSE, ERROR,
OR OMIISSION RESULTING IN SUCH ISSUANCE. SHOULD IT BE DETERMINED AT ANY TIME BY ST. LOUIS COUNTY THAT THE AUTHORIZED CONSTRUCTION NEEDS TO BE REMOVED, MOVED,
CORRECTED, OR MODIFIED IN ANY FASHION, THAN SUCH REMOVAL OR CORRECTIVE WORK WILL BE AT OUR EXPENSE.
Contractor Name & Address
Tel No.
Reg #
Signature
Fax #
Date
Printed Name
Email
Applicant Other Than Contractor
Name & Address
□ Owner, □ Architect, □ Engineer, □ Tenant, □ Other _____________________
Tel #
Reg #
Signature
Fax #
Date
Printed Name
Email
Page 1 of 2 (Print/Copy As A 2-Sided Document Is Preferred)
TYPE OF WORK
New Construction
Addition
Alteration
Replacement
Repair
Foundation
Shell
Interior Finish
Fire/Storm Damage
Occupancy
Miscellaneous Work
TYPE OF STRUCTURE
RESIDENTIAL
MULTI-FAMILY
3 or 4 Multi-Family
5 or more MultiFamily
Single-Family
Two-Family
Townhouse(s)
Units/Building _________
Units/Permit___________
Note: Two-Family and
Townhouse type buildings
must have independent
dwelling units with individual
entrances. No common areas.
Note: Multi-Family buildings
have common areas such as
common entry stairs, corridors,
hallways, breezeways, and/or
common basement areas.
BUILDING – TEMPORARY STRUCTURE
Type of Structure:
Membrane Structure,
Trailer on Wheels,
Size of Structure: Area _______ sq. ft.,
Stage/Platform Structure,
Tent,
Other (describe)__________________
Width: ______ ft., Depth/Length _____ ft.
The structure has the following built-in systems/facilities (check applicable boxes):
Heating system,
Cooling system,
Toilet facilities w/ holding tank
If the structure does not have built-in toilet facilities, indicate below the location of the
nearest toilet facilities that will be available to the occupants of the temporary structure:
Location: _________________________________________ Distance away: ______ ft.
Intended use of structure: __________________________________________________
Hours of operation: ___________, Dates of operation: __________________________
For food & beverage service facilities list the items offered and provide copy of menu:
_______________________________________________________________________
Structure is
owned,
leased/rented by the applicant.
If leased/rented, applicant shall complete the following:
Structure owner: ______________________ Contact person: _________________
Owner’s address: _______________________________ Phone #: ____________
Applicant’s anticipated removal date: _____________
(must comply with criteria below)
Note: Permits for membrane structures including tents are limited to less than 90 days. Permits for
all other temporary structures are limited to the time of service or length of season, not to exceed 6
months. Temporary classrooms may be erected for a maximum period of 9 months. Unoccupied
display structures and subdivision sales offices may be erected for a period of up to 1 year. All
temporary structures must be removed from the site by the expiration date of the permit.
Comments/Information: ___________________________________________________
Other Permit References: _____________________________________________________
Estimated Cost of Temporary Structure and Installation:
COMMERCIAL
ASSEMBLY
Theatres
Restaurant
Night Club
Churches/Religious
Recreation Center
Exhibition Hall
Banquet Center
Taverns & Bars
BUSINESS
Office/Bank/Professional
Carwash
Clinic
Fire Station
Doctor’s Offices
Laboratories
EDUCATION
Schools
Child Day Care
FACTORY/INDUSTRIAL
Manufacturing Plant
Industrial Laboratories
Utilities
HIGH HAZARD
Flam. & Comb. Liquids
Storage or Manufacturer
Tire Storage (Bulk)
Other High-Hazard
Storage or Manufacturer
INSTITUTIONAL
Nursing Home
Day Nurseries
Hospitals
Jails
Residential Care and
Assisted Living
MERCANTILE
Retail/ Wholesale/Stores
Service Station
Markets
RESIDENTIAL
Dormitories
Hotels/Motels
STORAGE
Office/Warehouse
Lumber Yard
Repair Garage
Parking Garage
NON-HABITABLE
Antennas
Attached Garage
Barn
Carport
Detached Garage
Fence
Fireplace
Generators
Patio Cover
Patio/Deck/Porch
Pergola
Res. Greenhouse
Retaining Walls
Shed
Signs
Solar Panel/Array
Swimming Pool
Tanks
Tower
Trash Enclosure
Other
Parking Lot
FOR OFFICE USE
Zoning Dist. ___________
Gov’t / Public Owned
PERMIT FEES
Processing ____________
Building ____________
Electrical ____________
Plumbing ____________
Mechanical ____________
Drainlaying ____________
Piers
____________
Foundation ____________
Land Disturb. __________
Inspection ____________
Penalty
____________
_________ ___________
Total Fees ____________
Filing Fee Pd __________
Balance Due ___________
Fees Paid ____________
$____________
Date
Issued _____/_____/_____
Issued By _____________
FOR OFFICE USE
Record Check____________________
Violation Check__________________
Permit Expiration Date: ________________
APPROVALS & DATE
Est. Cost ______________
Transient Employer Documents
Notified__________________Date______
#OP_____________
PA
Flat
Closet
Zoning Rev. ____________
Plan Rev. ______________
PAC No. _________________________
Box No. ______________
Folder
Permit No._________________________
Page 2 of 2 (Print/Copy As A 2-Sided Document Is Preferred)
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TEMPORARY STRUCTURES SUBMITTAL INSTRUCTIONS
Please allow a minimum of four (4) weeks for processing the application after being received by the
Department of Public Works.
The following information is required to be submitted in order to obtain a building permit to erect, place, or construct
a temporary structure:
1.
A completed application for Temporary Structure permit. Application forms are available at the Public Works
Permit Counter or can be downloaded from the Public Works web site at
www.stlouis.com/YourGovernment/CountyDepartments/PublicWorks.
2.
A cash surety deposit (see attached form) or a performance bond (see attached form) made payable to the
“Treasurer of St. Louis County, Missouri” for the following amounts:
TYPE OF TEMPORARY STRUCTURE
CASH SURETY/BOND AMOUNT
Structures or trailers used as residential subdivision sales offices ……………………….……$1,000.00
Tents, including tent canopies:
 Tents larger than 2000 sq. ft. up to 10,000 sq. ft………………………………………$500.00
 Tents larger than 10,000 sq. ft………………………………….……………………..$1,000.00
Trailers on Wheels (other than above real estate or sales offices):
 Snow cone & similar small trailers up to 200 sq. feet…………………………………$200.00
 Single wide trailers up to 1000 sq. feet…………………………………………………$500.00
Stages (without roof/canopy):
 Stages larger than 500 sq. ft. up to 1000 sq. ft…………………………………………$200.00
 Stages larger than 1000 sq. ft…………………………….$500.00 plus additional $100.00 for
each additional 500 sq. ft. or fraction
thereof.
All Other Temporary Structures
 All other temporary structures……………………………. Minimum of $500.00 for structures
(such as membrane covered cable
up to 1000 sq. ft. For structures
or frame structures, air-inflated or
greater than 1000 sq. ft. a minimum
air-supported structures, large trailers
of $1000.00 plus an additional
on wheels, structures with removable
$200.00 for each 500 sq. ft. or fraction
wheels, structures on skids, stages
thereof.
with roof canopies, etc.)
Note: The Code Official may, at his
discretion, set a higher bond amount on
large unique structures that are more
permanent in nature and not easily
removed.
Cash escrow/Bond amount listed is for each temporary structure (i.e., 2 subdivision sales trailers
would require a $2,000.00 cash surety deposit/bond amount).
Permits for tents and tent canopies to be used for sales promotions or display shelters and those used
on church property for worship or other religious purposes may be issued without posting a cash surety
deposit/performance bond.
The cash surety deposit /bond shall guarantee the removal of the structure at the direction
of the Director of Public Works or upon expiration of the permit. Please see the “Cash Surety
Deposit/Temporary Structure Bonds Information” sheet for an acceptable cash surety deposit/bond format.
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3.
Six (6) site plans showing the location of the structure in relation to any other existing structures on the site
and the distances to the property lines. Please contact County Zoning Review, 314-615-2525, or the Zoning
Official of the contracting municipality, if within a contracting municipality, for placement restrictions for a
particular parcel.
4.
Six (6) complete sets of plans identifying how the structure will be anchored and or braced to resist wind
loads referenced by the County Ordinance 24,444, Chapter 1115 SLCRO and Chapter 16 of the ’09 IBC as
amended. St. Louis County Public Works reserves the right to request plans and/or structural calculations
prepared and sealed by the appropriate Missouri Registered Design Professional.
5.
Four (4) sets of plans and details for anything that is to be field constructed (i.e. entrance stairs, landing,
ramp, deck, canopy) and/or four (4) sets of plans for the temporary trailer.
6.
The flame resistance of the tent fabric shall be verified by an affidavit documenting the following information
for all tent structures:
a.
b.
c.
d.
e.
Names and addresses of the owners of the tent structure.
Date the fabric was last treated with flame resistant solution.
Trade name or kind of chemical used in treatment.
Name of person or firm treating the material.
Name of the approved testing agency and test standard by which the fabric was tested. The
membrane material shall meet one of the following criteria:
Noncombustible (Section 704.4)
or
Flame resistant when tested in accordance with small-scale and large scale tests in NFPA
701-96.
or
Treated in an approved manner to render the material flame resistant.
7.
All temporary structures shall either provide, or have nearby access to, an adequate water supply, plumbing
facilities, and sewerage disposal in accordance with the Plumbing Code, Chapter 1103 SLCRO, as amended.
If the temporary structure has toilet facilities within, the applicant must provide a letter to Plumbing
Inspections specifying the method of sewage disposal (i.e. temporary hook-up to sewer line, holding tank,
etc.). Include a copy of the contract with the waste hauler, if a holding tank is to be used, with the letter.
Jim Showmaker, Plumbing Inspections (314-615-0330)
St. Louis County Public Works Department
th
41 S. Central Avenue, 6 Floor
St. Louis, MO. 63105
8.
Zoning approval from St. Louis County Zoning Review (314-615-2525) or from the Zoning Official of the
contracting municipality if the temporary structure is to be located within a contracting municipality.
9.
Fire District or Fire Department approval. (see attached form)
10.
Property Owners or Lessee’s Permission form sealed, signed and dated for St. Louis County or a municipality
contracting with St. Louis County to enter the site. (refer to attached form)
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TEMPORARY STRUCTURE CASH SURETY DEPOSIT INFORMATION
In order to obtain a temporary structure permit, the owner and/or operator of the temporary
structure may be required (see submittal instructions) to post a cash surety deposit for the
stipulated amount with the Treasurer of St. Louis County, to guarantee removal of the structure
upon expiration of the permit or at the direction of the Director of Public Works.
The cash surety deposit submitted shall consist of:
A) The temporary structure cash surety deposit form. (Must be signed and dated by the
owner/operator of the temporary structure)
B) Cash, money order, or check for the stipulated sum to be deposited with the Treasurer of St.
Louis County.
The temporary structure cash surety deposit shall be submitted in the same form as the attached sample
without alterations.
TEMPORARY STRUCTURE BOND INFORMATION
In lieu of providing the cash surety deposit noted above, a performance bond must be posted to guarantee
removal of the structure upon expiration of the permit or at the direction of the Director of Public Works.
The bond submitted shall consist of:
A)
The temporary structure bond. (Must bear the seal of
Surety Company and Principal if a corporation.)
B)
The power of attorney.
C)
The notary acknowledgment.
The temporary structure bond shall be submitted in the same form as
the attached sample without alterations.
Revised 03/07/02
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St. Louis County Counselor
TEMPORARY STRUCTURE CASH SURETY DEPOSIT
I/We as owner(s) and/or operator(s) of a temporary structure proposed to be located at
______________________________________________ are held firmly bound unto
(address of temporary structure location)
The Treasurer of St. Louis County, Missouri a cash surety deposit in the sum of ___________________________________
Dollars ($_____________) for which sum we bind ourselves, our heirs, executors, administrators, successors and assigns,
jointly and severally, firmly by these presents.
The Condition of this obligation is such that
WHEREAS, I/We have requested that I/We be granted a permit by St. Louis County to construct a temporary structure at
______________________________________________________________
______________________________________________________________________________________________________
____________________________________________________________
(hereinafter referred to as “temporary structure”); and
WHEREAS, I/We agree that upon the expiration of the building permit or lawful extension thereof, authorizing this temporary
structure, the temporary structure must be removed from its site noted above and that site returned to its condition immediately
prior to the construction of the temporary structure (hereinafter referred to as “original condition”);
WHEREAS, I/We agree that if the temporary structure is not removed upon the expiration of the building permit or lawful
extension thereof, authorizing the temporary structure, St. Louis County may cause the temporary structure to be removed
and/or demolished and the site returned to its original condition; and
WHEREAS, I/We agree that this cash surety deposit is to reimburse St. Louis County for all reasonable expenses incurred in the
removal and/or demolition of the temporary structure and in any work necessary to return the site to its original condition;
NOW, THEREFORE, I understand that if I comply with all applicable ordinances of St. Louis County or any municipality within
St. Louis County and upon expiration of the building permit authorizing said temporary structure, remove the temporary structure
and return the site to its original condition, then this obligation to be void; otherwise, this obligation shall remain in full force and
effect.
This cash surety deposit shall be construed to cover the interests of any Municipality in St. Louis County and shall be available
for the protection of such Municipalities and the residents of St. Louis County and any Municipality within St. Louis County.
This cash surety deposit shall remain in effect until the Director of Public Works, or his designee, has inspected the site and is
satisfied that the temporary structure has been removed from the premises and the site returned to its original condition. Once
the temporary structure has been removed and the site restored to its original condition, I/We may request that the cash surety
deposit be returned.
Temporary Structure owner/operator Name: ___________________________________
Signature: _____________________________
Date: _____________________________
STATE OF MISSOURI)
COUNTY OF ST. LOUIS)
SS
On this __________ day of ______________________, 20____, before me personally appeared
____________________________________________, who being sworn, stated that he/she is the person named above and
that he/she executed the same as his/her free act and deed.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
__________________________________
My commission expires:
Notary Public
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TEMPORARY STRUCTURE BOND
(SAMPLE)
KNOW ALL MEN BY THESE PRESENTS, that we,
(Name of Principal)
as Principal, and the
(Name of Surety Company)
,a
(State)
corporation, as Surety, are held and firmly bound unto The Treasurer of St. Louis County, Missouri, as Obligee, in
the sum of _________________
________________ Dollars ($_______________) for which sum, well and truly to be paid, we bind ourselves, our
heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents.
Signed, sealed, and dated this ______ day of ____________________, 2_______.
The Condition of this obligation is such that
WHEREAS, the Principal has been or is about to be granted a permit by St. Louis County to construct a temporary
structure at (Location of Temporary Structure)
____________________________________________________________________________________________
______________________________________________
(hereinafter referred to as “temporary structure”); and
WHEREAS, the Principal and Surety agree that upon the expiration of the building permit authorizing this temporary
structure, the temporary structure must be removed from its site at (Location of Temporary Structure)
_____________________________________________________________________
and that site returned to its condition immediately prior to the construction of the temporary structure (hereinafter
referred to as “original condition”);
WHEREAS, the Principal and Surety agree that if the temporary structure is not removed upon the expiration of the
building permit authorizing the temporary structure, St. Louis County may cause the temporary structure to be
demolished and the site returned to its original condition; and
WHEREAS, Surety agrees to reimburse St. Louis County for all reasonable expenses incurred in the demolition of
the temporary structure and in any work necessary to return the site to its original condition;
NOW, THEREFORE, if the Principal shall comply with all applicable ordinances of St. Louis County or any
municipality within St. Louis County and upon expiration of the building permit authorizing said temporary structure,
remove the temporary structure and return the site to its original condition, then this obligation to be void; otherwise,
this obligation shall remain in full force and effect.
This bond shall be construed to cover the interests of any Municipality in St. Louis County and shall be available for
the protection of such Municipalities and the residents of St. Louis County and any Municipality within St. Louis
County.
This bond shall remain in effect until the Director of Public Works, or his designee, has inspected the site and is
satisfied that the temporary structure has been removed from the premises and the site returned to its original
condition.
Revised 04/11/01
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TEMPORARY STRUCTURE BOND
KNOW ALL MEN BY THESE PRESENTS, that we, ____________________________
as Principal, and the __________________________________________________, a
_________________ corporation, as Surety, are held and firmly bound unto The Treasurer of St. Louis
County, Missouri, as Obligee, in the sum of _________________
________________ Dollars ($_______________) for which sum, well and truly to be paid, we bind
ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by
these presents.
Signed, sealed, and dated this ______ day of ____________________, 2_______.
The Condition of this obligation is such that
WHEREAS, the Principal has been or is about to be granted a permit by St. Louis County to construct a
temporary structure at __________________________________
_____________________________________________________________________________________
_______________________________________________________
(hereinafter referred to as “temporary structure”); and
WHEREAS, the Principal and Surety agree that upon the expiration of the building permit authorizing this
temporary structure, the temporary structure must be removed from its site at
_________________________________________________________
_____________________________________________________________________
and that site returned to its condition immediately prior to the construction of the temporary structure
(hereinafter referred to as “original condition”);
WHEREAS, the Principal and Surety agree that if the temporary structure is not removed upon the
expiration of the building permit authorizing the temporary structure, St. Louis County may cause the
temporary structure to be demolished and the site returned to its original condition; and
WHEREAS, Surety agrees to reimburse St. Louis County for all reasonable expenses incurred in the
demolition of the temporary structure and in any work necessary to return the site to its original condition;
NOW, THEREFORE, if the Principal shall comply with all applicable ordinances of St. Louis County or any
municipality within St. Louis County and upon expiration of the building permit authorizing said temporary
structure, remove the temporary structure and return the site to its original condition, then this obligation to
be void; otherwise, this obligation shall remain in full force and effect.
This bond shall be construed to cover the interests of any Municipality in St. Louis County and shall be
available for the protection of such Municipalities and the residents of St. Louis County and any
Municipality within St. Louis County.
This bond shall remain in effect until the Director of Public Works, or his designee, has inspected the site
and is satisfied that the temporary structure has been removed from the premises and the site returned to
its original condition.
Revised 04/11/01, 10/11/10
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INSURANCE/BONDING COMPANY NAME ___________________________________
BOND # ___________________
ACKNOWLEDGEMENT OF PRINCIPAL
(Firm / Corporation / Individual)
PRINCIPAL:_________________________________________ (contractor's company name)
By: ________________________________________________ (signature of company's responsible officer)
(name and title typed or printed below)
STATE OF ______________________ )
COUNTY OF ____________________ ) SS
On this _________ day of _______________, 20 _____, before me personally appeared
_____________________________ (name of company officer) the above signed officer who acknowledged himself/herself to
be the ___________________(title) of ______________________________ (name of company) and that he/she as such officer
being authorized to do so, executed the foregoing instrument for the purposes therein contained by signing the name of the
______________________________ (company name)
a _______________________(company/corporation/partnership) by himself/herself as such officer.
In witness whereof, I hereunto set my hand and official seal.
__________________________________________
Notary Public
My commission expires:_____________________
ACKNOWLEDGEMENT OF SURETY
SURETY: ______________________________________
(Name of insurance / bonding company)
By: ____________________________________________
(Signature of Attorney-in-Fact)
STATE OF ______________________ )
COUNTY OF ____________________ ) SS
On this _________ day of _______________, 20 _____, before me personally appeared
____________________________________, who being sworn, stated that he/she is attorney-in-fact for surety,
_____________________________________, and that he/she signed this instrument as attorney-in-fact for the foregoing surety.
_________________________________________
Notary Public
My commission expires:_____________________
APPROVED AS TO LEGAL FORM:
_________________________________
St. Louis County Counselor
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FIRE PROTECTION DISTRICT OR FIRE DEPARTMENT APPROVAL
OF
TEMPORARY STRUCTURE PERMIT
TO:
Temporary Structure Permit Processing
Department of Public Works
Code Enforcement Division
St. Louis County Government Center
41 S. Central Avenue, 6th Floor
Clayton, MO 63105
FROM:
__________________________________________________________
(FIRE PROTECTION DISTRICT OR FIRE DEPARTMENT)
County Application No.: _______________
Municipality: ________________
Applicant’s Name: ___________________________ Phone Number: ______________
Mailing Address: _______________________________________________________
Address & Location of Temporary Structure___________________________________
Proposed Use of Structure:
Date of Usage:
__________________________________________
From_______________________ To _______________________
FIRE DISTRICT OR DEPARTMENT APPROVAL OF THE TEMPORARY STRUCTURE
As required by Section 3104.16 of St. Louis County Ordinance 20311, 1-05-01, approval is hereby given by
the Fire Protection District or Fire Department for the Temporary Structure noted above.
Approved by: ____________________________________ Date: ________________
Title: ________________________________________________________________
Note: Applicants for Temporary Structure permits must submit this form verifying Fire
Protection District or Fire Department approval of the temporary structure to St. Louis
County, Department of Public Works before a permit can be issued for the structure.
All temporary structures must be removed by the expiration date of the permit. Permits for
membrane structures including tents are limited to less than ninety (90) days. Permits for all other
temporary structures are limited to time of service or length of season, not to exceed six (6)
months, except for classroom structures which are permitted for ten (10) months, and unoccupied
display structures and subdivision sales offices which are permitted for a period up to one (1) year.
Revised 02/12/13
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PROPERTY OWNER’S OR LESSEE’S PERMISSION FOR ST. LOUIS COUNTY OR MUNICIPALITY
CONTRACTING WITH ST. LOUIS COUNTY TO ENTER THE SITE
This is to certify that I am the owner or lessee, or authorized legal agent of either, of the property (land) located at
_________________________________________________
(address of temporary structure location)
being the site where a permit to construct a temporary structure is requested from St. Louis County Department of
Public Works (hereafter referred to as “St. Louis County”).
I understand that before such permit is granted by St. Louis County the owner/operator of the proposed temporary
structure may be required to provide St. Louis County with a performance bond or cash surety deposit to ensure the
removal of the temporary structure should the owner/operator of the temporary structure fail to remove the structure
upon the expiration of the temporary structure permit.
Should the temporary structure owner/operator fail to remove the temporary structure by the permit expiration date,
or lawful extension thereof, I _________________________, as the property owner or lessee, or authorized legal
agent of either, having the authority to grant permission as noted herein, hereby grant permission to St. Louis County
or any municipality within the County that contracts with the County for code enforcement, or their agents, to enter
the site for the purpose of removing or demolishing the temporary structure and any work necessary to return the site
to its original condition.
IN TESTIMONY WHEREOF, I execute this instrument and accept the above understandings and conditions of
approval for the temporary structure permit.
Property Owner’s, Lessee’s or Agent’s Signature _______________________________
Date _______________________________
Printed Name ______________________________
STATE OF MISSOURI)
COUNTY OF ST. LOUIS)
Phone# ____________________
SS
On this __________ day of ______________________, 20____, before me personally appeared
____________________________________________, who being sworn, stated that he/she is the person named
above and that he/she executed the same as his/her free act and deed.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
_____________________________________
Notary Public
My commission expires:
Revised 02/12/13
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