Road Occupancy and Encroachment Application

Road Occupancy and Encroachment Application

Date of Application

Project Number

Proposed Start Date

Proposed Completion Date

Pavement Cut?

Yes

No

Sidewalk Cut?

Yes

No

Work in Ditch?

Yes

No

Work on Road?

Yes

No

Proper Signage Available?

Yes

No

Road Closure Required?

Yes

No

Check All That Apply

Road Bore

Road Cut

Curb Cut

Tile Drain

Section One - Property Owner/Contractor Information

Roll Number

Lot

Concession

Property Owner

Phone Number

Owners Address

E-Mail Address

Company/Contractor

Company/Contractor Address

Company/Contractor Phone Number

Company/Contractor Email

Type of Installation

Location of Work

Contact Person

Licence Number

Insurance Policy and Certificate Attached?

Yes

No

Signature of Application of Company/Contractor

Clear

Section Two - Traffic Impact

Please Select All That Apply

No Road Closure Required

Road Closure/Detour

Road Restriction/One Way Traffic

Flaggers Lane Closure

Sidewalk

Traffic Impact

Shoulder Closure/Lane Shift

Other (Please Describe Below)

A traffic control plan must be submitted three (3) working days prior to construction. If work will take longer to complete, a subsequent plan must be summited until the work is completed.

Fee:
A fee of $126.00 Payable to the Township of Southgate (Fees and Charges effective February 5, 2025, By-law 2025-014)

Received

Yes

No

Date

Initial

For Staff Use Only

Section Three - Drawings - See Attached Drawing
The location of construction must be carefully diagrammed.

Please Upload Drawings Below

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Public Works Manager Authorization

Clear

Date

Forms