APPLICATION FOR PERMIT TO

OCCUPY A ROAD ALLOWANCE

District of Saanich – Engineering

Permits issued will satisfy the requirements of The Streets and Traffic Regulation Bylaw, 2002, No 8382 Section 8.04

The Municipality requires forty-eight (48) hours to process the permit application.

Date: ______

NOTE: All data fields must be filled out for the application to be processed. Please put N/A in any field that does not apply to this permit.

1.  Address of road/roads to be Occupied: ______

2.  Dates of Occupation: ______= ______Total Days

3.  Type of Occupation: ______

Please list all (i.e. site trailer, material storage, access for construction, etc.)

4.  Area of Occupation: ______m Wide X ______m Long = ______Square Metres

5.  Cost - (Minimum $5.00, calculated either by area or frontage, whichever cost is greater).

a.  For each 10 sq m or portion thereof = $0.75 per day

# of Areas of 10 sq m or a portion =______x $0.75 x ______days = $______

b.  For each 7 m of frontage or portion thereof = $0.75 per day

# of Frontages of 7 m or a portion = ______x $0.75 x ______days = $______

Permit Cost = Greater of “a” or “b” or $5.00 Minimum $______

6.  Saanich File No. (if applicable): ______Saanich Design Drawing No: (if applicable):______

(Found on design drawing. or correspondence) Drawing showing location of proposed occupation is required.

7.  OWNER □ or CONTRACTOR □ (Check one)

Company / Contact
Address
City / Postal
email / Phone

8.  Proof of Insurance on file with Saanich? * Yes * No * Don't know

Valid Proof of Liability Insurance Coverage for $2,000,000 is required before Saanich can issue a permit. The Insurance form must name the District of Saanich as an Additional Insured. Certificate of Insurance form is available upon request.

9.  Statement

We declare that we are the Owner or Project General Contractor and that the information provided is accurate and complete.

Signature: ______

Freedom of Information and Protection of Privacy Act (FIPPA). This collection of personal information is authorized under the Local Government Act, Community Charter and section 26(c) of FIPPA. The information will be used for processing this application. Please note that particulars about this permit including the owner name and civic address will be treated as public information and may be used for reporting and statistical purposes. Questions can be directed to the District’s Information and Privacy Team at 770 Vernon Avenue, Victoria, BC V8W 2W7 Tel. 250-475-1775; Email: .

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