Required fields are marked with asterisks (*)

Application for a Road Occupancy Permit

Township of Uxbridge

Public Works and Operations Department

If you are applying for a Road Occupancy Permit to lay new fiber, you MUST contact the Works and Operations Department directly at 905-852-9181 ext. 202 or via email to nmessina@uxbridge.ca

For Municipal Consent, please contact Ben Kester bkester@uxbridge.ca

Please provide today's date - mm/dd/yyyy

Name of Applicant (or company name)

Please provide your telephone number

Address

Email address

The undersigned hereby applies for a permit to occupy the following street:

Please provide street name

Between

And

Occupation date:

Duration of time:

Traffic will be detoured via

Map of location, if applicable or available

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Please indicate if this permit will or will not require Excavation

No Excavation - $125.00

With Excavation - Fee $300.00

FiberOptics, Fundraisers or Township Work

I have reviewed Township of Uxbridge By-law No. 78-37

Agree

Please provide proof of insurance

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I/we hereby agree to comply with all the provisions in By-law No. 78-37 with respect to the work for which this application is made and to the conditions set forth here (need to place conditions link) to this application and agree to assume all costs incurred by the Corporation of the Township of Uxbridge as a result of the aforesaid closure or occupancy.

Please ensure the following agencies have been notified:

Uxbridge Fire Department
Police Department
Transit Bus Department
News Media Outlets

*Any breach of the conditions of this permit is subject to a penalty not exceeding the $300.00 plus costs.

Please provide digital signature

Clear