APPLICATION/ PERMIT NUMBER TOWNSHIP OF ESSA PUBLIC WORKS DEPARTMENT ROAD OCCUPANCY PERMIT APPLICATION FORM (Please Print) Application Date: APPLICANT INFORMATION Phone Number Applicant Name Mailing Address Fax Number 24 Hr. Contact 1: 24 Hr. Contact 2: Name: Name: Phone number ( ) Phone number ( Email address ) Email address OWNER INFORMATION Phone Number ( Utility/Property Owner Name Mailing Address ) Email address ACTIVITY LOCATION Date of Occupancy (end date) Date of Occupancy (start date) A sketch of the specific property/area must be completed. indicate north House No. Road Name Road Name ………………………………………………… Boulevard Road Name Cut Location Length Width Area Depth Road Shoulder or Boulevard Sidewalk (draw on map) ACTIVITY INFORMATION The purpose of the Occupancy is: Excavation Building Utility Sanitary Sewer Municipal Water Enclose Ditch Traffic Restrictions: As required None Lane Full Traffic Plan Provided Date: AGREEMENT I, the undersigned have read and understood the information provided and agree to abide by all general conditions, special provisions and all conditions listed on the face and back of this Permit Application and Permit, if issued. Authorized Representative Signature Date Fee $ ………….. Receipt # ……..…. Deposit $ ………. Sheila Perri, Engineering Development Review Technician Email: [email protected] Fax: 705-424-2367 Receipt # ………. Date CONDITIONS OF APPROVAL The following conditions shall apply in all cases when work is intended to be carried out on a Township Municipal Road Allowance: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Any person or persons intending to occupy or perform work on Township of Essa property, must first apply to the Public Works Department for a Road Occupancy Permit. Approval must be obtained from the Manager, or his/her designate, prior to the commencement of work. The permit must be in the name of the person or persons performing the intended work, and not in the name of an agent acting for them. The Applicant must indicate the intended starting date and duration of such closure or occupancy, at least 48 hours in advance of starting the work described in the permit. Where time extension is required, the holder of this permit shall apply for such extension at least 24 hours in advance of the stated date of re-opening. Time extensions must be authorized by the Manager of Public Works or his/her designate, before taking effect. Failure to comply will render this permit void. The Applicant and/or the Contractor shall have and/or take out and keep in force, a comprehensive policy of public liability and property damage insurance acceptable to the Municipality, providing insurance coverage in respect of any one accident to the limit of at least $1,000,000. exclusive of interest and cost, against loss or damage resulting from bodily injury to, or death of, one or more persons and loss of or damage to property and such policy shall name the Municipality as an additional insured thereunder, and shall protect the Municipality against all claims for all damage or injury including death to any person or persons, and for damage to any property of the Municipality, or any other public or private property, resulting from or arising out of any act or omission on the part of the Applicant, or any of his servants or agents during the course of the intended works, and final acceptance thereof by the Manager of Public Works. The Applicant shall forward a certified copy of the policy or certificate thereof, to the Township of Essa, before the work is started. The Applicant, his agent or Contractor, shall abide by all Acts, By-laws and Regulations relative to the performance of the work and the Applicant and/or the Contractor shall provide all necessary excavating and trenching support systems, shoring, timbering or other devices to conform therewith. The Applicant and/or Contractor shall provide and ensure that all agents, workmen and servants, are wearing the prescribed safety equipment, to conform with all Acts, By-laws, and Regulations (ie: hard hats, safety boots, vests, etc.). The permit becomes null and void if the Applicant and/or the Contractor should fail to meet the requirements of the permit, in which case, the Manager of Public Works or his designate shall take such action as he deems necessary to reinstate the site for public protection, at the expense of the Applicant. In all cases, the decision of the Manager of Public Works is final. All barricades, signs, signals, flagmen, traffic control devices, detour design and signing shall meet the requirements of the Ministry of Transportation’s Manual of “Uniform Traffic Control Devices”, and shall be the sole responsibility of the Applicant and/or the Contractor. The Applicant and/or the Contractor shall maintain access to all public and private properties for the duration of the work. Any and all excavated materials may not be piled in such a manner as to obstruct vehicular or pedestrian traffic. It shall be the Applicant’s and/or the Contractors responsibility to request marking or other location information, to determine the location and provide safeguards for all utilities, both public and private, in accordance with current regulations. Depending on the depth of a sewer lateral or trunk line, and/or watermain, the Applicant and/or Contractor may be required to provide and operate a proper de-watering system, satisfactory to the Manager of Public Works prior to excavation being carried out. As well, an additional well point placed in the general area of the works may be required to monitor the elevation of the water level in relation to the Municipal watermain or sewer trunk line. In all cases, the need for such de-watering devices shall be determined and approved by the Manager of Public Works. No sewer or water connections shall be permitted on municipal road allowances after December 1st annually unless weather conditions are satisfactory to the Manager of Public Works. The Applicant and/or Contractor shall be required to provide a Letter of Credit, cash deposit, or certified cheque made payable to and in favour of the Corporation of the Township of Essa for the value of the work, as estimated by the Manager of Public Works, prior to the work being carried out, to ensure permanent repairs are completed as expeditiously as possible. The Manager of Public Works may reduce the amount of the deposit or waive the deposit entirely, if in his opinion the works being undertaken are not likely to result in damages to the travelled portion of the roadway. The Township of Essa may complete any work required to be done by an Applicant, Owner, and/or Contractor, or may rectify any action of an Applicant, Owner, and/or Contractor which is contrary to the permit and such work done by the Township of Essa shall be completed at the expense of the Applicant, Owner, and/or Contractor. The Township of Essa may carry out any work required to be done and deduct the same from the deposit, Letter of Credit, or certified cheque, and all forthwith refund the amount by which the sum deposited exceeds the costs of repairs. The Applicant and/or the Contractor shall pay the Municipality for all engineering and inspection fees associated therewith and the same may be deducted from the Letter of Credit, cash deposit, or other securities posted with the Township of Essa. Clay, in fluid state, frozen material, organic matter, silt or mud shall be excluded from backfill. This may require that part or all of the excavated material be replaced by sand or crushed stone backfill. The material to a depth of four (4) feet below the finished road surface shall be kept separate from any material excavated below this depth. These two layers of material must be replaced in the trench in the same layers from which they were excavated. Backfill materials shall be compacted in layers, the maximum thickness being six (6) inches except in the case of granular base course material for which the maximum depth of each compacted layer shall be four (4) inches. If undue settlement occurs at a later date, an additional charge will be made for repair. In the travelled portion of the road, if the native backfill exhibits conditions as noted under Item 15 above, and requires replacement, the trench walls must be excavated to a minimum 2:1 (horizontal-vertical) sloped to a maximum depth of four (4) feet below the road surface. Likewise the depth of existing granular base course materials shall be replaced in kind. Under no circumstance shall any of the previously excavated material from the trenches be used as Class “A” granular base course material. In addition, if any of the excavated granular base course material becomes contaminated, the Contractor shall not use it as granular base course Class “B” material. All sodded areas, ditches, culverts, and driveway entrances shall be repaired or replaced promptly. All surplus material shall be removed, the area cleaned and returned to its original condition. A temporary patching having a minimum thickness of two (2) inches shall be placed in all areas where asphalt has been removed. Final and permanent repair shall be carried out by the Applicant to the satisfaction of the Manager of Public Works. The decision of the Manager shall be final. The Applicant shall be responsible for the repair for a period of one (1) year from the date of approval of this Permit. The foregoing is in compliance with the current policy of the Corporation of the Township of Essa in respect of Occupancy of Municipal Roads within the Municipality.
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