Version: 17-07-2015
Non-Utility Minor Works within Municipal
Road Reserves - Permit Application
This notification / application is provided in accordance with 1. Road Management Act 2004, Schedule 7
2. Road Management (Works and Infrastructure) Regulations 2005
Use this form for: (i) Notification of proposed works, (ii) Application for consent, or (iii) Notification of completed works to the Coordinating Road Authority
This Application is subject to Approval – For any queries please contact Council.
APPLICANT DETAILS
Type:
(Tick)
1. Application for consent
2. Notification of proposed works
Role:
Please Circle or
Specify
3. Notification of Completion
Mitchell Shire Council
To:
Owner or
2.
Occupier or
3.
Other (specify)
Yes
Yes
_____ / _____ / 20____
Date
From:
1.
Planning
Permit Number
(Applicant’s Name)
Address:
Telephone
(BH):
Telephone
(AH):
Facsimile
(Applicant’s address)
City/Town:
State:
Postcode:
Contact
person:
Mobile
FEE
email address:
$
BOND
$500
$
TOTAL
DETAILS of WORK – To be assessed against relevant standards
Work Type
(Tick)
1. Service
connection
2. Drainage
connection
3. Vehicle Crossing
4. Other works
(specify below)
Proposed
Start Date:
__ /__ / 20__
City/Town:
Address of
works:
Description of
works: (include list
of assets affected by
works)
A Sketch Plan Must be Provided - A copy of a site plan showing the proposed location of works, including all assets
within the vicinity and dimensions of the works and to nearby assets. Assets include all trees, landscaping, road pavement,
kerb & channel, footpaths, drains, service authority assets and private assets affected by the works.
WORKS MANAGER DETAILS - Any person or body that is responsible for the conducting of works in, on or under the road. (Road
Management Act – Schedule 7, Clause 14)
Contractor or
Company Name:
Contractor/Company
ABN:
Contractor’s
Address:
Name of Works
Manager*:
E-mail address:
Telephone (BH):
Facsimile:
Mobile :
Does the contractor have Public Liability
Insurance? (Yes/No)
Amount of P.L. Cover:
$
Name of Public Liability Insurance
Company:
Does the proposal require the removal of any vegetation (If yes please provide details or a
photograph). This request will be considered by Council. There is no guarantee that approval will be
YES / NO
given and further permits maybe required.
SIGNATURE (please read both front and back of application)
COUNCIL APPROVAL (Valid for 6 months from date below)
Applicant:
Engineer:
DATE:
DATE:
Works Manager Responsibilities:
Principles applying to infrastructure managers and works managers:
(1) An infrastructure manager or a works manager must have regard to the principles specified in this clause in the provision of nonroad infrastructure on roads.
(2) The primary purpose of a road is use by members of the public and authorised users must be managed as far as is reasonably
practicable in such a way as to minimise any adverse impacts on the primary purpose.
(3) Without limiting the generality of sub-clause (2), authorised uses must be managed so as to –
a. minimise any damage to roads and road infrastructure;
b. ensure that works necessary for the provision of non-road infrastructure are conducted as quickly as practicable;
c. minimise any disruption to road users;
d. minimise any risk to the safety and property of road users and the public generally;
e. facilitate the design and installation of infrastructure which minimises any risk to the safety of road users;
f. ensure that the road and any other infrastructure is reinstated as nearly as practicable to the condition existing before the
works necessary for the provision of the non-road infrastructure were conducted;
g. protect and preserve existing significant roadside vegetation and sites of biological significance within the road reserve.
(Road Management Act - Schedule 7, Sec 14)
Traffic Management:
Any works conducted within the road reserve may require a Traffic Management Plan to ensure the safety of the public and workers.
Works managers must assess this requirement and where required submit a Traffic Management Plan and apply for a Memorandum of
Authorisation (MOA) through the relevant Road Manager.
For works impacting Council Roads applications can be located via the link below or through our customer service centres:
http://www.mitchellshire.vic.gov.au/services/building-planning-and-transport/roads-infrastructure/roads-infrastructure-permits-forms
Privacy Statement: “Personal information collected by Council is used for municipal purposes as specified in the Local Government Act, 1989 or other
relevant legislation. The personal information will be used solely by Council for these purposes and or directly related purposes. Council may disclose this
information to other organisations, if required by legislation. The applicant understands that the personal information provided is for the above purpose and
that he/she may apply to Council for access to and/or amendment of the information. Requests for access and/or correction should be made to Council’s
Privacy Officer. - 113 High Street, Broadford, Vic, 3658 DX 66003 Seymour TEL: (03) 5734 6200 FAX: (03) 5734 6222
E-MAIL: [email protected] Internet: www.mitchellshire.vic.gov.au
ROAD OPENING PERMITS FEES & BONDS 2015/16
Type of Works
New Vehicle Crossing
Vehicle Crossing Extension & Stormwater
Connection
Water Tapping/Service Connection
MAJOR WORKS
Works of more than 8.5m square, conducted on any part of the road way,
shoulder or pavement. (i.e. road trenching and major drainage or road
works) * - Minimum Bond. Additional bond maybe required for significant works
Refundable Bond
Fee
$500.00
$319.60
$500.00
$500.00
$126.50
$81.60
$1000.00*
$586.20
Permit Validity:
The Permit is valid for six (6) months from the date of Engineering Approval.
Inspection Requirements:
Vehicle Crossover, Extensions and Stormwater Connection require pre pour and post pour inspections.
Water tapping/Service Connections require post work inspections.
Major Works require a pre-commencement meeting and agreed inspection points.
BEFORE YOU SUBMIT YOUR APPLICATION HAVE YOU PROVIDED?
1.
2.
3.
4.
A site plan drawn to scale with all dimensions of your proposed works.
Any assets that may be affected by the proposed works must be detailed on the plan.**
Your contractors information including public liability information.
Payment of your application.
Please be aware that failure to provide any of the above items will delay the processing of your
application.
This application is NOT approved until you receive a signed copy of this form and an approval
letter from Council.
** A Sketch Plan Must be Provided -
A copy of a site plan showing the proposed location of works, including all
assets within the vicinity and dimensions of the works and to nearby assets. Assets include all trees, landscaping, road
pavement, kerb & channel, footpaths, drains, service authority assets and private assets affected by the works.