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| Contractor street address: |
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| Contractor city, country, postal code: |
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| Project details & work location address (please include name, location, address & civic address, plan or lot #) : |
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| Prime Contractor, contact name: |
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| Prime Contractor, office #: |
| Enter a valid phone number. Example: 123-456-7890 |
| Prime Contractor, cell #: |
| Enter a valid phone number. Example: 123-456-7890 |
| Prime Contractor, 24-hour call #: |
| Enter a valid phone number. Example: 123-456-7890 |
| Enter a valid phone number. Example: 123-456-7890 |
| Enter a valid email address. Example: name@company.com |
| Engineering Consultant, contact name: |
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| Engineering Consultant, office #: |
| Enter a valid phone number. Example: 123-456-7890 |
| Engineering Consultant, cell #: |
| Enter a valid phone number. Example: 123-456-7890 |
| Engineering Consultant, fax #: |
| Enter a valid phone number. Example: 123-456-7890 |
| Engineering Consultant, 24-hour call #: |
| Enter a valid phone number. Example: 123-456-7890 |
| Engineering Consultant, email: |
| Enter a valid email address. Example: name@company.com |
| Geo Technician, contact name: |
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| Geo Technician, office #: |
| Enter a valid phone number. Example: 123-456-7890 |
| Enter a valid phone number. Example: 123-456-7890 |
| Geo Technician, 24-hour call #: |
| Enter a valid phone number. Example: 123-456-7890 |
| Enter a valid phone number. Example: 123-456-7890 |
| Enter a valid email address. Example: name@company.com |
| Traffic Control Supervisor, contact name: |
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| Traffic Control Supervisor, office #: |
| Enter a valid phone number. Example: 123-456-7890 |
| Traffic Control Supervisor, cell #: |
| Enter a valid phone number. Example: 123-456-7890 |
| Traffic Control Supervisor, 24-hour call #: |
| Enter a valid phone number. Example: 123-456-7890 |
| Traffic Control Supervisor, fax #: |
| Enter a valid phone number. Example: 123-456-7890 |
| Traffic Control Supervisor, email: |
| Enter a valid email address. Example: name@company.com |
| Note: the prime contractor is to immediately notify the Operations Clerk of any changes, including contact information, permit conditions, location changes, etc... |
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| Detailed description of work activity: |
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| Work Safe notice of project: |
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| File # (required only if answered YES to Notice of Proceed): |
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| Permit date/time requested & scheduled work details |
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| Provide work schedule detail as required. |
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| 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. |
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| Excavated site surface material(s): Asphalt |
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| Excavated site surface material(s): Concrete |
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| Excavated site surface material(s): Other |
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| Traffic Information: Road Name and Direction |
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| Traffic Information: Where on Roadway |
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| Traffic Information: Condition(s) |
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| Traffic control plan detail are included (if no, a TMP needs to be faxed prior to starting work). |
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| 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). |
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| By checking this checkbox, |
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| As signing authority for the Prime Contractor, by clicking this box: |
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| Applicant Name (signature) |
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