Road Cut Application

Information of permit holder

First name of permit holder

Last name of permit holder

Name of the company holding the permit

Address of the permit holder

Phone number of permit holder

Email of permit holder

For businesses, please provide the name of the contact person

Phone number of the contact person

Email of contact person

Contractor

Business name

Business permit number registered in Hawkesbury

Business address (#, street, unit,city, postal code)

Full name of project manager

Phone number of project manager

Email of project manager

Provide the contact details of an emergency contact – available 24/7

If this field is left blank, the emergency contact will be the project manager.

______________________________________________________________

Work details proposed

Describe the proposed work in detail; be specific.

Sketch of the proposed location, including existing and requested widths (m)

Refer to the example above

_______________________________________________________________

Information about the location for the road cut

Location 1

Work start date

Work end date

Indicate the address of the road cut, or the name of the street (geographic coordinates preferred)

Indicate the size of the road cut in square meters

__________________________________________________________________

Location 2

Start date

End date

Indicate the address of the road cut, or the name of the street (geographic coordinates preferred)

Indicate the size of the road cut in square meters

_______________________________________________________________

Traffic Management Information

Indicate the street(s) affected by the closure (Street name, direction of the closed lane). Provide the reasons for the requested closure.

In Compliance with the Ontario Traffic Manual (Book 7)

______________________________________________________________

Approvals, agreements, and consents

Please check the appropriate boxes and include their reference number. Don’t forget to attach supporting documents.

Residential, commercial, or industrial development application Municipal consent Building permit number Other (Please specify in project description section)

Reference number for development application

Reference number for municipal consent

Reference number for building permit

Other

Supporting documents

________________________________________________________

Professional service fees

________________________________________________________

Permit holder declaration

I understand that:

The total amount of fees will be provided to me in accordance with the professional service fees outlined in the municipal by-law of the Town of Hawkesbury.
The fees do not include testing services or any other necessary services. These additional costs will be added to the associated fees.
Fees may be adjusted depending on the nature and complexity of the project.
All fees must be paid before the permit is issued by the Town.
Fees must be paid in person at Town Hall, either by cheque, debit, or cash.

Please note: The permit is valid for one year from the date of issuance. After this date, a new permit must be requested, which will also include the applicable issuance fees.

I acknowledge

That as the permit holder, I am responsible for ensuring that the conditions of this agreement are respected by myself and by any person working on my behalf.
That all individuals involved in this project must comply with Road Activity By-law No. 2003-445. Each person must adhere to municipal regulations and work diligently with the staff of the Town of Hawkesbury.

I declare that all information provided in this application, including any attachments, plans and estimates, and any other documents, is accurate to the best of my knowledge.

Signature of permit holder

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