Application for Road and Sidewalk Occupation Permit

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_____________________________ 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 ***************************************************************************************************** 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)
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Application for Road and Sidewalk Occupation Permit

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