Operations and Community Services
148 Line 7 South
Oro-Medonte, ON
L0L 2E0
APPLICATION FOR ROAD OCCUPANCY PERMIT
General Information
Owner Name/Company Name:
Address:
Business Telephone No.:
Fax No.:
Applicant’s Name (if different from above) :
After hours Contact:
Telephone No.:
Type of Work and Purpose Location
Drawing
Conditions for issuance (Special Provisions)
The Applicant agrees and accepts full responsibility for the protection of all utilities, private property and persons affected by his/her operations
and further agrees to provide proof of liability insurance as per Township standards naming the Township of Oro-Medonte and Simcoe County as
additional insured
($5,000,000 min.); and further indemnify and save harmless the Township of Oro-Medonte and all assets and personnel it is in law responsible for.
Failure to comply with all conditions will render this permit void.
It shall be the applicant’s responsibility to ensure compliance with site plan, zoning, connect ion approval
and all other relevant
regulations
Duration Approved,
From:
Duration required,
From:
To:
To:
Township of Oro-Medonte Approval
Date
Applicant’s Signature Date
Application Fee
Security Deposit
Paid
Amount $
Paid
Amount $
General Conditions
148 Line 7 South.
(
705
)
487-2171
1.
Prior to commencing work, locates must be obtained from all utilities in the Township of Oro-Medonte.
2.
The Township designate must be notified 48 hrs before work is to commence, at
3.
When working, a copy of this permit
and Locates must be on site at all times.
4.
This permit is not valid until the signed copy is received by the Township of Oro-Medonte.
5.
Two copies of construction plans must be submitted with this permit.
6.
The return of the permit or copy to this office is notification of completion of work and restoration of site.
7.
All applicants shall provide final as-constructed drawings in electronic format approved equivalent as requested.
8.
Positive drainage shall be maintained during the course of the work.
Indicate
North
Repair:
Road
Name:
Municipal #.:
New:
Legal
Property
Description
:
Plan
No.:
Pavement
Cut
Insurance
Certificate
Trench
/
Pit
YES NO
Road Cut
Access
Augered/Bored
Road
Crossing
Access
Width: Culvert
-
Length: Diameter: Curb
Cut
-
Length: Paved
Gravel
Permit
#:
Final Inspection
Date
I, ____________________________________________ hereby declare that I have read, understand and will comply with the
requirements of By-law 2017-063 - Road Occupancy. The information submitted is to be true and accurate.
Signature of Owner ____________________________ Signature of Applicant ____________________________
□
□
□
Road Occupancy Permit Fees
$125.00 Permit Fee (Non-refundable)
$150.00 Road Cut Fee (Non-refundable)
$100.00 Re-inspection Fee
$40/sq.m 0-15 years Pavement Degradation Fee
$20/sq.m 16-30 years Pavement Degradation Fee
$0/sq.m Greater than 30 years Pavement Degradation Fee
By-law No. 2017-063
ZONE #: _____
Road Cut Permit Fees
(Do Not Complete Shaded Areas)
(office use only)
