Application for Road and Sidewalk Occupation Permit

THE CORPORATION OF THE TOWN OF HEARST
925, Alexandra St., P.O. Bag 5000, Hearst, Ontario POL 1NO
Tel: (705) 362-4341 Fax: (705) 362-5902
APPLICATION FOR ROAD AND SIDEWALK OCCUPATION PERMIT NO. R&S:______
pursuant to By-law No. 26-84 as amended
Please complete all appropriate lines and check all appropriate boxes
1. APPLICANT: OWNER OF RELEVANT ABUTTING LAND:
same as applicant or
Name:_____________________________________
Name:______________________________________________________
Mailing address:____________________________ Mailing
address:______________________________________________
____________________________________________
Phone
#:____________________________________________________
Phone #:___________________________________
Civic
Address:________________________________________________
Fax #:__________________ e-mail:______________ Property File
#:________________________________________________
2. THIS APPLICATION IS REQUIRED FOR THE PURPOSE OF:
a) CONSTRUCTING/INSTALLING NEW, OR REPAIRING/REPLACING EXISTING:
SANITARY SEWER SERVICE
WATER SERVICE
STORM SEWER SERVICE
UNDERGROUND ELECTRICAL SERVICE
COMMERCIAL VEHICLE ENTRANCE ___________WIDE DOMESTIC VEHICLE ENTRANCE _________ WIDE
NATURAL GAS SERVICE
UNDERGROUND TELEPHONE CABLE SERVICE
UNDERGROUND TELEVISION CABLE SERVICE
OTHER ________________________________
AND/OR
b) OBSTRUCTING AND/OR OCCUPYING HIGHWAY/SIDEWALK/BOULEVARD/OTHER MUNICIPAL LAND TO:
ERECT SCAFFOLDING TO CONDUCT WORK ON ABUTTING LAND UNDER THE BUILDING CODE ACT
STORE MATERIALS TO CONDUCT WORK ON ABUTTING LAND UNDER THE BUILDING CODE ACT
PROVIDE SAFETY MEASURES AND CONTROL TRAFFIC WHILE CONDUCTING WORK ON ABUTTING LAND
UNDER THE BUILDING CODE ACT
FOR RELATED MUNICIPAL BUILDING/DEMOLITION PERMIT NO. ____________
3. LOCATION AND TYPE OF MUNICIPAL LAND AFFECTED: SIDEWALK DRAINAGE DITCH
TRAVELLED PORTION OF HIGHWAY/ROAD_____________________ BOULEVARD/UNTRAVELLED PART
ALLOWANCE
UNOPENED ROAD ALLOWANCE_____________________________ CONCRETE CURB AND GUTTER
BETWEEN ________________________________ AND _______________________________________; OR
OTHER MUNICIPAL LAND DESCRIBED AS, Parcel _____________________ Lot/Part
___________________________________
in Plan/Concession ____________________________ Township
________________________________________________
Civic
Address:
__________________________________________________________________________________________
4. TIME PERIOD FOR WORK SPECIFIED IN SECTION 2 TO BE CARRIED OUT/COMPLETED:
FROM_______________________________________
_________________________________________________________
TO
5. DETAILS OF WORK TO BE CONDUCTED AS SPECIFIED IN SECTION 2:
________________________________________________________________________________________________________
_
________________________________________________________________________________________________________
_
________________________________________________________________________________________________________
_
________________________________________________________________________________________________________
_
6. SAFETY MEASURES/CONTROLS TO BE IMPLEMENTED FOR PARTIAL ROAD CLOSURE TOTAL ROAD CLOSURE:
BARRICADES, TO BE PLACED
______________________________________________________________________________
SIGNS, TO BE PLACED
____________________________________________________________________________________
FLAGMEN, TO BE PLACED
_________________________________________________________________________________
DETOUR TO BE IMPLEMENTED
_____________________________________________________________________________
OTHER
________________________________________________________________________________________________
7. RESTORATION TO BE EFFECTED:
TRAVELLED/OPENED HIGHWAY, ROAD: Minimum 500 mm of Granular B type 1 gravel sub-base, 150 mm Granular A gravel
for base course compacted to 95% standard proctor, and asphalt pavement to same depth as existing surface (minimum
40mm), unless otherwise required by Director of Public Works
CONCRETE CURB AND GUTTER : Cut and remove existing curb and gutter and match to adjacent
SIDEWALK Minimum 150 mm Granular A gravel for bedding and minimum thickness 125 mm 20Mpa concrete
BOULEVARD: Match existing with minimum 75 mm compacted topsoil, sodded or seeded or asphalt
pavement
DITCH: fine grade to match existing slope, 75 mm topsoil and sodded or seeded, with erosion control

_____________________________ if necessary at inlet and outlet of culvert
ENTRANCE/DRIVEWAY: minimum 150 mm Granular A gravel and minimum 40 mm of asphalt pavement.
NOTE: ALL RESTORATION EFFECTED TO BE EQUAL TO OR BETTER THAN CONDITIONS PRIOR TO WORK BEING
CARRIED OUT PURSUANT TO THIS PERMIT.
8. PLANS SUBMITTED IN SUPPORT OF THIS APPLICATION:
Site plan Construction drawing(s) Specification(s)

9. APPOINTMENT OF AGENT
I, ___________________________________________, do solemnly declare that I have appointed
(name of property owner)
_____________________________________________ as my agent for the purposes of this application.
(name of agent)
__________________________________________________
(date)
__________________________________________
(signature of owner)
10. DECLARATION
I, ___________________________________________, solemnly declare that the information provided herein and
(name of applicant)
also submitted in support of this application is true, accurate and complete.
I hereby declare that I will carry out the safety control measures stated in Section 6 of this my application; the restoration measures
stated in Section 7 hereto; and that I will further notify and obtain the approval of the Director of Public Works prior to making any
changes to the time period specified in Section 4 hereto and/or the scope and nature of the work to be undertaken and for which this
application is hereby made. I hereby further declare, covenant and agree to carry out and complete all restoration work at my own risk
and expense and in accordance with the aforementioned specifications and requirements and to the satisfaction of the Corporation of
the Town of Hearst.
__________________________________________________
(date)
_________________________________________
(signature of applicant)
ROAD AND SIDEWALK OCCUPATION PERMIT
Fee paid ________________________ Permit No. ________________________ Receipt No.
______________________________
A ROAD AND SIDEWALK OCCUPTION PERMIT IS HEREBY ISSUED TO
___________________________________________________
OF_________________________________________________________________________________________________________
(address)
AS REQUESTED IN THE PRECEDING APPLICATION, PURSUANT TO BY-LAW NO. 26-84 OF THE CORPORATION OF THE
TOWN OF HEARST; DURING THE TIME PERIOD SPECIFIED AS
__________________________________________________________________
AND SUBJECT TO THE FOLLOWING CONDITIONS:
___________________________________________________________________________________________________________
_
___________________________________________________________________________________________________________
_
___________________________________________________________________________________________________________
_
_______________________________________
(Date)
_____________________________________________
(Signature of Director of Public Works)
Failure to comply with the terms and conditions of this permit and/or the plans on the basis of which this permit was issued and/or the
requirements of By-law No. 26-84 and amendments thereto of the Corporation of the Town of Hearst constitutes an offence against
said by-law and may result in a fine of $2,000.00
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VERIFICATION OF CONDITIONS
DAMAGE VERIFICATION ON THE __________________ DAY OF __________________________________ 20____
NO DAMAGE
DAMAGES OBSERVED AND FURTHER RESTORATION REQUIRED: _____________________________________________
___________________________________________________________________________________________________________
_
___________________________________________________________________________________________________________
_
___________________________________________________________________________________________________________
_
___________________________________________________________________________________________________________
_
ESTIMATED REPAIR COST $__________________________ INSPECTED BY
________________________________________
RESTORATION VERIFIED AS BEING COMPLETED FULLY AND SATISFACTORILY.
_______________________________________
(Date)
_____________________________________________
(Signature of Director of Public Works)