APPLICATION FORM ATTACHMENT 1
APPLICATION FORM FOR UTILITY SERVICE PROVIDERS & LOCAL GOVERNMENT
Details of Applicant- Utility Service Provider (Principal Agency) or Local Government)
(Principal Agencies are Western Power, Water Corporation, Telstra, ATCO Gasetc. and not their contractor, subcontractor or other organisation undertaking works on behalf of the Principal Agency).
Name and Address of Utility Service Provider or Local Government
Principal Contact Details
Name Phone Fax
Mobile Email
Existing Agreements
Reference of any relevant existing Agreements with Main Roads WA for undertaking works within the Road Reserve. (e.g. Memorandum of Understanding).
Authorised Agent on behalf of the Utility Service Provider
(Refer to Note 1, Page 13 below)
Company Business Name Address
Contact Details
Name Phone Fax
Mobile Email
Details of the Applicant’s Contractor
Fill in this section if the works are to be undertaken by someone other than the Applicant (a contractor or sub-contractor).
Company Business Name Address
Contact Details
Name Phone Fax
Mobile Email
Project Manager Phone/E-mail
Field Representative Phone Fax
After Hours Contact Phone 1 Phone 2
Details of Proposed Works
Your Reference Number
Location of Proposed Works
Exact Location (include road names, distance to nearest cross street and map reference)
Local Government Proposed Start Date Duration
Suburb/Town Proposed Hours of Work
Description of Proposed Works
(e.g. type of utility service; size of pipe/conduit; depth of service below ground level; location of service from fence line; location of work with reference to a road feature such as a road intersection, bridge, culvert, etc.; and attach a sketch/drawing if necessary).
Method for Proposed Works
(Including trenching, line boring, installation casing, filling with grout, remove/replace, install new, add to service, remove redundant, position/alignment, depth of service, etc.).
ENVIRONMENTAL AND HERITAGE CONSTRAINTS
(Environmental Checklist)
Applicants are required to complete the following Projects Works Environmental Checklist (see Table 1 below) in regards to the proposed project works. In order to minimise delays in the application process, applicants are required to submit additional supporting information in relation to the checklist (for example, Clearing Permit Number, licences or other approvals granted). Evidence of this additional documentation should be provided with this application. The applicant is required to obtain all necessary approvals, permits and licences for the proposed project works.
If the proposed works require the clearing of native vegetation, a native vegetation clearing permit must be obtained by the applicant prior to the commencement of project works in accordance with the Environmental Protection Act, 1986. The applicant’s clearing permit number will need to be provided to MRWA with this application. Clearing permits are issued by the Department of Environment and Conservation (DEC) and these permits are the responsibility of the applicant. Information regarding native vegetation clearing permit applications can be found at:
use
Table 1- Project Works Environmental Aspects Checklist
Item No. / Environmental Aspect / Checklist (Yes/No/ NA) / Provide Evidence of Permit/Approval/LicenceDo the project works require the clearing of vegetation? (No, proceed to item no. 5)
1 / a. What is the quantity of vegetation to be cleared?
2 / a. Do the project works require the clearing of native vegetation?
b. Have all necessary approvals been obtained to clear native vegetation?
c. Has a native vegetation clearing permit been obtained to clear native vegetation?
d. What is the clearing permit number for the proposed project works? / e.g. Clearing permit no. 23/658
3 / a. Does the project area contain Aboriginal Heritage Sites?
b. Have all necessary approvals been obtained to disturb Aboriginal Heritage? / e.g. Section 18 Application No.
4 / a. Does the project area contain Cultural Heritage Sites?
b. Have all necessary approvals been obtained to disturb Cultural Heritage? (end of checklist for Clearing Permit holders)
If no native vegetation clearing is required, do the project works:
5 / Impact dieback or other pathogens located within the project area?
6 / Impact contaminated sites located within the project area?
7 / a. Impact wetlands/watercourses located within the project area?
b. Have all necessary approvals been obtained to disturb wetland/watercourses?
8 / a. Impact surface/groundwater located within the project area?
b. Have all necessary approvals been obtained to disturb surface water/groundwater?
9 / Impact acid sulfate soils located within the project area?
10 / Generate soil erosion, flooding or salinity within the project area?
11 / Generate dust?
12 / Generate noise/vibration?
13 / a. Impact Aboriginal Heritage sites located within the project area?
b. Have all necessary approvals been obtained to disturb Aboriginal Heritage?
14 / Impact European Heritage sites located within the project area?
b. Have all necessary approvals been obtained to disturb Cultural Heritage?
Utility Service Provider (Principal Agency) Declaration
•Utility Service Providers are familiar with Main Roads WA Policy and associated Guidelines regarding Utility Services in Road Reserves.
•Installation, maintenance and management of utility services conform with the current edition of the Utility Providers Code of Practice for Western Australia (UPCOP);
•The Utility Service Provider acknowledges that all necessary environmental and other statutory approvals have been obtained, particularly related to clearing;
•For roads other than declared Control of Access, the Utility Service Provider agrees to meet the costs of installation and any future maintenance, repair or modification of the utility service; and Main Roads will consider the merits of seeking a contribution from the utility service provider towards the cost of a future relocation, should this be required due to road works, on a case by case basis. In the case of declared Control of Access road reserves, refer to Note 2, Page 8 below.
•The Utility Service Provider undertakes to accept all liability associated with the installation, repair, maintenance and ongoing operation of the service;
•Any damage to Main Roads’ road reserves and assets attributed to the works shall be immediately restored by the Utility Service Provider to their pre-construction/disturbance condition, to the satisfaction of Main Roads. The worksite will be left in a clean and tidy pre-construction condition, including revegetation of all the areas that have been cleared;
•The Utility Service Provider agrees to indemnify and keep indemnified the Commissioner of Main Roads for all damage to any Main Roads’ assets / road furniture arising from the installation of, or as a result of the presence of, the utility service;
•The Utility Service Provider agrees to indemnify, and keep indemnified, Main Roads WA, its employees, contractors and agents (but excluding the Utility Service Provider, its employees, contractors, sub-contractors or agents):
a) from and against all actions, suits, claims and demands taken, made or brought by any person against Main Roads WA in respect of:
I) the death or injury of any person; and
II) the loss or damage to property (whether real or personal); and
b) for the loss of, or any damage to, any property of Main Roads WA, its employees, contractors, sub-contractors or agents;
in the course of, arising out of, or caused directly by, the works the Utility Service Provider undertakes under this Application, except to the extent the relevant loss, damage, injury or death is caused by the negligence of those indemnified.
•All work will be carried out in accordance with the requirements and information contained in this Application and relevant legislative and statutory requirements.
Endorsement
I hereby certify that this application contains a true and accurate description of the proposed works. All works will be carried out in accordance with the information contained in this application and legislative and statutory requirements and to any other conditions or specifications imposed by Main Roads.
Signed: ______
Duly authorised officer of the Applicant(Refer Note 1 below)
Name of Signatory: ______
(PRINT)
Position: ______
On behalf of: ______
Date: _____ / _____ / _____
Please note that incomplete applications may cause delays. Please refer all applications and enquires to appropriate Main Roads office. Contact details are listed in the Attachment 3. Main Roads will advise you in writing of any requirements to be met.
Main Roads will advise applicants in writing of any requirements to be met.
Note 1: Where the endorsement is made on behalf of the Utility Service Provider (Principal Agency) a letter from the Principal Agency must be attached to this Application as confirmation that the Authorised Agent is acting directly on behalf of the Principal Agency.
Note 2: For road reservations declared Control of Access under section 28A of the Main Roads Act (1930), a Utility Service Management Agreement will be required to be prepared and submitted by the Utility Service Provider as an attachment to this Application.
PUBLIC NOTIFICATION REQUIREMENTSATTACHMENT 2
Applicants must ensure that the text of all media advertisements, announcements, information leaflets or advanced information signage is approved by Main Roads prior to issue.
The type of public notification, if required, will be one or more of the following:
•Placing a display advertisement in The West Australian Early General News section and the local Community Group Newspaper or Independent Newspaper one week prior to works commencing. For works exceeding 3 weeks, advertisements may have to appear in the local newspapers each week following the mandatory initial advertisements in The West Australian and local newspapers (extent of advertising to be discussed with the Main Roads Public Affairs Branch). Information details are to include project description, work cycle period, nature of disruption and contact information.
•Arrange radio and TV announcements.
•Erecting advance information signage on each approach to the work site at least 10 working days prior to start of works but not exceeding 21 working days.
•Distributing an information leaflet (via a letterbox drop) to all residents and businesses within the 100 meters of the work site and along any detour routes required at least seven (7) working days prior to start of the works.
Guidelines for Determining the Method of Public Notification
•All proposed works that will exceed 4 continuous hours and will result in an impediment to road users (including motorists, pedestrians, people with disabilities and cyclists), or results in delays exceeding 15 minutes to the road user, Applicants may be required to provide notification of such works in the print media.
•Where the proposed works will exceed 10 continuous hours, either during the day or night or over three (3) or more days that involve disruption to road users (including motorists, pedestrians, people with disabilities and cyclists), Applicants may be required to distribute an information leaflet, install advance information signage and place advertisements in the print media.
Further information on the type of public notification required can be obtained by contacting the appropriate Main Roads WA Regional Office shown in Attachment 1.
Lodgement of Advertisements with the Print Media
Applicants are responsible for the lodgement of approved advertisements with the print media at least 5 working days prior to start of works.
ATTACHMENT 2 (continued)
MAIN ROADS CONTACTSATTACHMENT 3
Please direct all enquiries to the Main Roads Customer Information Center on 138 138 or email to for Metro Region (ask for the Customer Services Manager)
For regional office, please visit the Main Roads website contact page:
(also ask for the Customer Services Manager)
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