Road permit application | City of Courtenay

Application date

Applicant's name

Business name

Phone number

Business address (with postal code)

Start date

Completion date

Address where work is occurring

Size of work area

Width

Depth

Length

Distance of works from curb or pavement edge

Is the work zone within K’ómoks First Nation’s designated areas of high archaeological potential (AOP)?

Yes

For more information on AOP requirements, visit K’ómoks First Nation cultural heritage investigation permits information. To view designated areas, see the K’ómoks First Nation archaeological potential map .

Purpose of works

Note whether the works are required as part of a Development Permit issued by Development Services

Describe what the road permit application is for, such as constructing scaffolding for building envelope work; placing a construction waste bin; completing offsite works such as sidewalks, curb and gutter, driveway letdowns, paving, water, sewer, storm or electrical works; service connections; service locates; test drilling, water quality monitoring.

I/We hereby agree to be bound by the provisions of the City of Courtenay Traffic Regulation Bylaw and amendments, if any, specifications, and regulations of the City governing works in or under municipal streets, and to such special conditions, restriction, and regulations as may be imposed by the Director or Engineering Services designate.

See conditions and regulations attached hereto.

Signature

Sign above

Applicant checklist

Please include the following with your road permit application:

Application fee ($100)

Preferred payment is by cash or cheque at the Operations Centre at 1000 Piercy Avenue. If needed, debit payments can be made at City Hall at 830 Cliffe Avenue.

Completed and signed road permit application and prime contractor attachment.

Sketch plan showing the proposed work and work zone, including the location of any subsurface works.

B.C. One Call notification dated within five days of the application.

B.C One Ticket number

WorkSafeBC clearance letter dated within five days of the application.

Registration number (if applicable)

Insurance for a minimum of $5,000,000 per occurrence, listing the City of Courtenay as an additional insured and including a 30-day notice of cancellation clause.

Business licence (Inter-Community business licence or City of Courtenay licence).

Traffic Control Plan

Supplementary documents

Maximum 5 files.
32 MB limit.
Allowed types: txt, pdf, doc, docx, ppt, pptx, xls, xlsx.

All submissions must be received at least 10 working days before the proposed start date.