APPLICATION FORMTraffic Obstruction Permit

PURPOSE OF APPLICATION

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Purpose of Application*

Moving Container/Bin
3rd Party Utilities/Test Wells
Soils
Filming
Special Events
Single Family Residential
Multi-Family/Ind./Com. (Specify Building Permit # below)
Land Development (Specify Project # below)
Capital Construction (Specify Contract # below)
Other (Please specify below)

Please provide details if required by choices selected above.

Project Address:*

APPLICANT INFORMATION

Permit Applicant Name:*

Phone:*

Address:*

Email:*

WorkSafe BC Registration No.*

Traffic Manager Name:*

24 Hr Phone:*

Email:*

Health & Safety Coordinator Name:*

Phone:*

Site Superintendent Name:*

Phone:*

Email:*

TRAFFIC CONTROL COMPANY INFORMATION

Traffic Control Co. Name:*

Phone:*

Email:*

DURATION

Expected Start Date:*

Expected Completion Date:*

Requested Hours:

From: (E.G. 10:30)*

To: (E.G. 5:30)*

OBSTRUCTION DETAILS

Temporary Full Road Closure*

Obstruction within 30 m of a Signalized Intersection*

Bus route Impacted*

Bus Stop Obstructed*

Parking Area Obstructed*

Pay Station Parking Area Obstructed*

Bike Lane Obstructed*

Sidewalk Obstructed*

Obstruction impacts Provincial Hwy*

School/Playground in close proximity*

Rear Lane (Alley) Obstructed*

The obstruction activity will take place on:
*

An arterial and/or collector road or have a significant impact on a local road such as a temporary full road closure.
A local road only and will have a minor impact on traffic.
An arterial/collector and local road

APPLICATION FORMTraffic Obstruction Permit

PURPOSE OF APPLICATION

Purpose of Application*

Project Address:*

APPLICANT INFORMATION

Permit Applicant Name:*

Phone:*

Address:*

Email:*

WorkSafe BC Registration No.*

Traffic Manager Name:*

24 Hr Phone:*

Email:*

Health & Safety Coordinator Name:*

Phone:*

Site Superintendent Name:*

Phone:*

Email:*

TRAFFIC CONTROL COMPANY INFORMATION

Traffic Control Co. Name:*

Phone:*

Email:*

DURATION

Expected Start Date:*

Expected Completion Date:*

From: (E.G. 10:30)*

To: (E.G. 5:30)*

OBSTRUCTION DETAILS

Temporary Full Road Closure*

Obstruction within 30 m of a Signalized Intersection*

Bus route Impacted*

Bus Stop Obstructed*

Parking Area Obstructed*

Pay Station Parking Area Obstructed*

Bike Lane Obstructed*

Sidewalk Obstructed*

Obstruction impacts Provincial Hwy*

School/Playground in close proximity*

Rear Lane (Alley) Obstructed*

The obstruction activity will take place on:*

APPLICATION FORM
Traffic Obstruction Permit

The obstruction activity will take place on:
*