Application Date

Location of Work (Street Number/Street Name/Postal Code)

Road Occupancy Permit Application

Applicant Information

Company Name

Contact Person

Street Number/ Name

City/ Town

Province

Postal Code

Telephone (Day)

Email Address

Work is being done on behalf of

Is the contrator the same as the applicant?

Yes

No

Permit Information

Occupancy Type

Work on Blvd. or Ditch

Utilities Install

Road Cut

Pavement/ Blvd. Drilling

Utilities Repair

Sidewalk Removal

Road Occupancy

Curb Cut

Have you applied for a Building Permit related to this project?

Yes

No

Type of Permit

Nature of Excavation

Hand Dig

Machine Dig

Trenching

Bore

Other

Work Description

Municipal Consent Number

Start Date

Completion Date

Utility Locates (NOTE: No work is permitted without locates)

Utility Locates Submitted

Copy of Locates attached

N/A

Date of Expiry

TRAFFIC PLAN - Will the following be affected? NOTE: Traffic Control Plans must be submitted if traffic is impacted

Two way vehicle traffic

Pedestrian Traffic

N/A

Attachments Included

Attachments

Certificate of Insurance

WSIB Certificate

Traffic Control Plan

Site Drawing

Other

Applicant Agreement

By executing this Application below, the Applicant agrees to the terms and conditions set out herein of this Permit. The Applicant also acknowledges and understand that the Permit and this application is subject to the Town’s Occupancy and Encroachment of Highways By‐law Number 6288-20, as amended or its successor. Failure of
the Applicant to comply with any of the terms and conditions of the Permit may result in action being taken by the Town, which may include a stop work being issued, charges being laid and fines being imposed pursuant to the Occupancy and Encroachment of Highways By‐law.

Resident Notification Provided

Yes

No

Signature of Applicant

Clear

Date

Form Builder

Road Occupancy Permit Application

Applicant Information

Permit Information

Attachments Included

Applicant Agreement