Road permit application

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

Purpose of Works

Please note whether or not works are required as part of a Development Permit issued by Development Services

Please fully describe what road permit application is for, ie. Construct scaffolding for building envelope work, placement of construction waste bin, offsite works such as construction of sidewalks, curb & gutter, driveway letdown, paving, water, sewer, storm & electrical works, service connections, service locates, test drilling, water quality monitoring etc.

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

For the attached Road Permit Application the following information is required:

Application Fee ($100)

Preferred payment is by cash or cheque at 1000 Piercy Avenue at the Operational Services Centre office. However, debit payment may be made at 830 Cliffe Avenue at City Hall if required.

Road Permit Application and Prime Contractor attachment completed and signed

Sketch Plan showing Works & Work Zone – please indicate location of subsurface works

Copy of B.C. One Call notification – dated within 5 days of application

B.C One Ticket No.

Workers Compensation Clearance Letter – dated within 5 days of application

Registration No.

Insurance in the amount of $5,000,000 per occurance that lists the City of Courtenay as an additional insured and includes a 30 day Notice of Cancellation clause.

Copy of Business License (Inter-Community or City of Courtenay)

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 Provided a Minimum of 10 Working Days in Advance