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Road Usage Permit Application Form

Permits will be approved or declined within 5 business days. Work cannot start without an approved permit and a copy of the approved permit must be on site at all times.

Please complete the application form below, preview and then submit (preview and submit buttons can be found at the top and bottom of the form).

A printed version of the application form can also be filled-out at City Hall.

If you have any questions, please contact City Yards at 250-469-8600.

For more information, view the Road Usage Permit application for details about Road Usage & Hording Permit Fees, the Traffic Control Plan (work zone site assessment form), the Traffic Plan Detail form, Temporary Asphalt Restoration Options, Excavation, Trenching & Backfilling, and Standard Drawing Details.

Page 1 of 1
Prime Contractor:
Contractor street address:
Contractor city, country, postal code:
Project details & work location address (please include name, location, address & civic address, plan or lot #) :
Prime Contractor, contact name:
Prime Contractor, office #:
 
Prime Contractor, cell #:
 
Prime Contractor, 24-hour call #:
 
Prime Contractor, fax #:
 
Prime Contractor, email:
 
Engineering Consultant, contact name:
Engineering Consultant, office #:
 
Engineering Consultant, cell #:
 
Engineering Consultant, fax #:
 
Engineering Consultant, 24-hour call #:
 
Engineering Consultant, email:
 
Geo Technician, contact name:
Geo Technician, office #:
 
Geo Technician, cell #:
 
Geo Technician, 24-hour call #:
 
Geo Technician, fax #:
 
Geo Technician, email:
 
Traffic Control Supervisor, contact name:
Traffic Control Supervisor, office #:
 
Traffic Control Supervisor, cell #:
 
Traffic Control Supervisor, 24-hour call #:
 
Traffic Control Supervisor, fax #:
 
Traffic Control Supervisor, email:
 
Note: the prime contractor is to immediately notify the Operations Clerk of any changes, including contact information, permit conditions, location changes, etc...
Detailed description of work activity:
Work Safe notice of project:
YesNo
Cost of project:
Notice to proceed:
YesNo
File # (required only if answered YES to Notice of Proceed):
Permit date/time requested & scheduled work details
Start date & time:
Pick date
:
End date & time:
Pick date
:
Provide work schedule detail as required.
YesNo
Note: end date is when all permanent surface restoration is complete & the contractor has notified the City. The permit must remain open until all work is complete. Failure to do so might result in legal action. Maintenance of the permit areas is the responsibility of the permit holder at all times, unless otherwise noted.
Excavated site surface material(s): Asphalt
CurbSidewalk/Walkway
RoadwayMin asphalt restoration (W) 1.45m
Excavated site surface material(s): Concrete
CurbSidewalk
RoadwayDriveway
Excavated site surface material(s): Other
BoulevardShoulder
MiscellaneousWithin 2m of a tree
Traffic Information: Road Name and Direction
Traffic Information: Where on Roadway
Curb LaneMedian LaneMedian
IntersectionRear Lane (alley)
Traffic Information: Condition(s)
Road Closure - local trafficRoad Closure - no traffic/detourSingle Lane - alternating traffic
Lane Closure - multi lane roadLane Closure - continually movingTraffic Control Person(s)
Traffic control plan detail are included (if no, a TMP needs to be faxed prior to starting work).
YesNo
Locates are required, prior to excavating, under the terms of the Road Usage Permit and WCB/Work Safe BC, Occupational Health and Safety Regulations; failure to do so will invalidate the Road Usage Permit. Application FEES are non refundable. All City Bylaws and regulations MUST be followed at all times. See Schedule "B" of KELOWNA TRAFFIC BYLAW NO 8120. Work CANNOT take place within 2m of a tree on a ROW without first obtaining approval from the Urban Forestry Supervisor (250 469-8503).
By checking this checkbox,
I (we) hereby acknowledge I have read and understood the City of Kelowna Traffic and Subdivision Bylaws and agree to be bound by its provisions and amendments, if any, specifications and regulations to the City governing excavations in or under municipal
Date of Application
Pick date
As signing authority for the Prime Contractor, by clicking this box:
I agree to the terms and conditions of this application.
Applicant Name (signature)
 

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