Temporary road occupancy Application

(1)

The hills shire CounCil

3 Columbia Court Baulkham Hills NSW 2153 PO Box 7064, Baulkham Hills BC 2153

Phone 02 9843 0555 email [email protected] Facsimile 02 9843 0409 www.thehills.nsw.gov.au

Temporary road occupancy Application

ABOut tHiS FOrm:

PArt 3: APPliCANt CHeCkliSt ANd deClArAtiON Please tick all applicable boxes below PArt 2: deSCriPtiON OF rOAd OCCuPANCy

title Given Name* Family Name*

i understand that if approved, i will comply with all conditions of approval (likely conditions of approval are found in the document “Schedule of temporary road Occupancy Conditions”)

I have attached a copy of a site specific Traffic Control Plan prepared by an RMS certified designer i have included a draft copy of the neighbour consultation letter

I have attached a copy of Public Liability Insurance Certificate, minimum of $10million

i understand that i must pay a road Occupancy Fee as detailed in Council’s “Fees and charges” prior to the approval being granted i understand the under certain circumstances, (e.g. work adjancant to or in close proximity to a State road, work in close proximity to traffic signals etc) I may be also required to obtain a separate Road Occupancy Licence from Roads and Maritime Services as a condition of Council’s approval

Between Street* and Street*

Street Name/Number

Suburb* Commencement date* duration*

Business/Company Name (if applicable)*

Company’s Function (i.e. owner, builder, sub-contractor etc)

Please describe the reason for the temporary road occupancy*

Suburb: Postcode:

Street address

telephone Number (W) (m) (F)

email:

Site Contact (if different to above) Position

this application is to be used when applying to temporarily occupy part of a public road or footpath which results in the need to manage pedestrian and/or vehicular traffic within the occupied area. It does not apply to work within a public road or footpath that (i) is subject to a separate Road Opening Permit. (ii) involves construction of future public assets and has been approved as part of a Construction Certificate.

(iii) requires a temporary full road closure and is subject to a separate Temporary Road Closure Application. (iv) is subject to a separate Driveway Application. (v) is carried out by or on behalf of, public utility authorities.

1. Ensure that all fields have been filled out correctly

2. Please note that fields on this form marked with an * are mandatory and must be completed before submitting the application.

3. Inadequate information will delay processing of your application and could incur further fees.

4. Once completed you can submit this form by mail, facsimile, email, or in person. Please refer to Part 4: lodgement details for further information

PArt 1: APPliCAtiON detAilS

HOW tO COmPlete tHiS FOrm

(2)

The hills shire CounCil

Mail: the Hills Shire Council PO Box 7064, Baulkham Hills BC 2153 email: [email protected]

in person at: Council Administration Building, 3 Columbia Court Baulkham Hills NSW 2153 (8.30am to 4.30pm, monday-Friday) Castle Hill library, Cnr Castle and Pennant Streets, Castle Hill

Vinegar Hill memorial library, 29 main Street, rouse Hill town Centre

Please note an application fee applies which must be paid when submitting this application

For further information regarding your application please contact us by email: [email protected] or visit our website:

www.thehills.nsw.gov.au

i declare that the information i have provided is true and correct, and that i have read and understood the “Schedule of temporary road Occupancy Conditions “ and agree to comply with them.

PArt 4: lOdGemeNt detAilS: you can lodge the completed application by:

PArt 5: WHAt NOW

PArt 6: PriVACy & PerSONAl iNFOrmAtiON PrOteCtiON NOtiCe

OFFiCe uSe ONly

Please send to Traffic team when fees have been receipted

Temporary road occupancy Application

Applicant Name*

date*

Applicant Signature*

Once your application is received a Council Officer will contact you if further information is required. If approved all fees must be paid before you will be issued with final conditions of approval, all of which must be complied with. The “Schedule of Temporary Road Occupancy Conditions” details likely conditions of approval.

Purpose of Collection: For assessment of a request for a temporary road occupancy intended recipients: Council staff and approved contractors of the Hills Shire Council

supply: A Temporary Road Occupancy Application is compulsary unless it meets the exemptions identified under

‘About this Form’. A completed application is required to occupy part of a road or footpath in any location in the Hills Shire Council local Government area.

Access/Collection: Council staff or Government Information (Public Access) Act requests.

storage: Council’s record management systems and archives

Receiving Officer (print name)

date receipt Number

(3)

The hills shire CounCil

Credit Card payment

option a – (to be completed if you are submitting credit card details with your application) Council will not store your credit card details

option b – (to be completed if you require a Council Officer to contact you for payments details) a $17.00 administrative processing fee applies to this option (includes gsT and merchant fee) Cardholder Name:

Name:

Name of Person to contact:

House and Street Number:

Name of Company: (if applicable)

Suburb: Postcode

Email:

Phone No.:

Reason for payment: (please tick) Application: Other: (please specify other)

Credit Card Type: Mastercard Visa

Credit Card No:

Expiry Date: CCV:

Amount: $ .

DETAILS FOR MAILING OF RECEIPT

OFFICE USE:

Date Time Officer Details

TO BE COMPLETED IF PAYING BY CREDIT CARD:

Payments are accepted for Visa & MasterCard.

PLEASE TICK PREFERRED OPTION:

CondiTions of use: If you have selected option “B” four (4) attempts will be made to contact you regarding your payment details, if after four attempts we are unsuccessful, your application/request will be returned.

privaCy noTifiCaTion: The personal information that Council has collected from you is personal information for the purposes of the Personal Information Protection Act (PPIPA) 1998. The intended recipients of the personal information are Officers within the Council data service providers engaged by the Council from time to time, any other agent/contractor of the Council and other statutory authorities. The supply of the information by you is not voluntary. Council has collected the information from you in order to process your request. You may make application for access or amendment to information held by Council. You may also make a request that Council suppresses your personal information from a public register. Council will consider any such application in accordance with the PPIPA. Council is to be regarded as the agency that holds the information. If you have any further enquiries concerning this matter, contact Council’s Public Officer on (02) 9843 0555. General information about the GIPA Act is available by calling the Office of the Information Commissioner on 1800 194 210 (free call) or at its website www.oic.nsw.gov.au.

(4)

Schedule of Temporary

road occupancy condiTionS

The conditions below are likely conditions to be imposed should the application be approved. This is provided so that pre-approval communication can be planned. This is not a formal approval. a separate notice will be issued once the application is approved.

1. all work being carried out in accordance with the approved Traffic Control Plan, which includes full traffic control of the inSerT road nameS (refer attached) in accordance with AS 1742.3 Manual of uniform traffic control devices.

2. The applicant must carry out a letter box drop to affected residents and /or business at least two weeks prior to the occupancy advising the nature and duration of the work as well as alternate traffic arrangements that will operate through the duration of the road occupancy.

3. The applicant must resolve, to the satisfaction of council any issues that arise as a result of representations made by affected residents or businesses.

4. The applicant must comply with any reasonable direction given by authorised council staff or the police during the period of the occupancy.

5. The applicant must indemnify council against all claims for damage or injury that may result from the road occupancy. The applicant must provide documentary evidence of public risk insurance cover for a minimum of $10 million for any one claim prior to the work commencing.

6. all costs associated with the road occupancy and required temporary notification will be borne by the applicant. This includes a road occupancy fee in accordance with council’s fees and charges.

7. The applicant will be required to reimburse council for the cost of repairing any damage to public assets during the period of the occupancy.

8. The applicant must not block vehicle driveway or pedestrian access to any premises unless written approval from the owner/occupants is first obtained.

9. The applicant will be required to liaise with the relevant bus company where the occupancy will impact on existing bus stops.

furTher informaTion

If you are unsure, please ask. Time spent early may avoid delays later.

Customer serviCe Centre

3 Columbia Court, Baulkham Hills NSW 2153 Phone 9843 0555

hours 8:30am —4:30pm, Monday —Friday Website www.thehills.nsw.gov.au

F A C t sheet

3 Columbia Court, Baulkham Hills NSW 2153 PO Box 7064, Baulkham Hills BC 2153

Phone 02 9843 0555 Email [email protected] Facsimile 02 9843 0409 www.thehills.nsw.gov.au