APPLICATION FORM
ATTACHMENT 1
APPLICATION FORM FOR UTILITY SERVICE PROVIDERS & LOCAL
GOVERNMENT
Details of Applicant - Utility Service Provider (Principal Agency) or Local Government)
(Principal Agencies are Western Power, Water Corporation, Telstra, ATCO Gas etc. and not
their contractor, subcontractor or other organisation undertaking works on behalf of the
Principal Agency).
Name and Address of Utility Service Provider or Local Government
Principal Contact Details
Name
Phone
Mobile
Fax
Email
Existing Agreements
Reference of any relevant existing Agreements with Main Roads WA for undertaking works
within the Road Reserve. (e.g. Memorandum of Understanding).
Authorised Agent on behalf of the Utility Service Provider
(Refer to Note 1, Page 13 below)
Company Business Name
MAIN ROADS Western Australia
Address
Contact Details
Name
Phone
Fax
Mobile
Email
Details of the Applicant’s Contractor
Fill in this section if the works are to be undertaken by someone other than the
Applicant (a contractor or sub-contractor).
Company Business Name
Address
Contact Details
Name
Mobile
Phone
Fax
Email
Project Manager
Phone/E-mail
Field Representative
Phone
Fax
After Hours Contact
Phone 1
Phone 2
MAIN ROADS Western Australia
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Details of Proposed Works
Your Reference Number
Location of Proposed Works
Exact Location (include road names, distance to nearest cross street and map
reference)
Local Government
Duration
Suburb/Town
Proposed Start Date
Proposed Hours of Work
Description of Proposed Works
(e.g. type of utility service; size of pipe/conduit; depth of service below ground level;
location of service from fence line; location of work with reference to a road feature
such as a road intersection, bridge, culvert, etc.; and attach a sketch/drawing if
necessary).
Method for Proposed Works
(Including trenching, line boring, installation casing, filling with grout, remove/replace,
install new, add to service, remove redundant, position/alignment, depth of service, etc.).
MAIN ROADS Western Australia
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ENVIRONMENTAL AND HERITAGE CONSTRAINTS
(Environmental Checklist)
Applicants are required to complete the following Projects Works Environmental Checklist
(see Table 1 below) in regards to the proposed project works. In order to minimise delays in
the application process, applicants are required to submit additional supporting information
in relation to the checklist (for example, Clearing Permit Number, licences or other approvals
granted). Evidence of this additional documentation should be provided with this application.
The applicant is required to obtain all necessary approvals, permits and licences for the
proposed project works.
If the proposed works require the clearing of native vegetation, a native vegetation clearing
permit must be obtained by the applicant prior to the commencement of project works in
accordance with the Environmental Protection Act, 1986. The applicant’s clearing permit
number will need to be provided to MRWA with this application. Clearing permits are issued
by the Department of Environment and Conservation (DEC) and these permits are the
responsibility of the applicant. Information regarding native vegetation clearing permit
applications can be found at:
http://www.dec.wa.gov.au/index.php?option=com_content&task=view&id=2919&Item
id=1780(or use http://www.dec.wa.gov.au/)
Table 1 - Project Works Environmental Aspects Checklist
Item Environmental Aspect
No.
Checklist Provide Evidence of
(Yes/No/
Permit/Approval/Licence
NA)
Do the project works require the clearing of vegetation? (No, proceed to item no. 5)
1
a. What is the quantity of vegetation to be
cleared?
2
a. Do the project works require the clearing
of native vegetation?
b. Have all necessary approvals been
obtained to clear native vegetation?
c. Has a native vegetation clearing permit
been obtained to clear native vegetation?
d. What is the clearing permit number for the
e.g. Clearing permit no.
proposed project works?
23/658
3
a. Does the project area contain Aboriginal
Heritage Sites?
b. Have all necessary approvals been
e.g. Section 18
obtained to disturb Aboriginal Heritage?
Application No.
4
a. Does the project area contain Cultural
Heritage Sites?
b. Have all necessary approvals been
obtained to disturb Cultural Heritage? (end
of checklist for Clearing Permit holders)
If no native vegetation clearing is required, do the project works:
5
Impact dieback or other pathogens located
within the project area?
6
Impact contaminated sites located within the
project area?
7
a. Impact wetlands/watercourses located
within the project area?
b. Have all necessary approvals been
obtained to disturb wetland/watercourses?
MAIN ROADS Western Australia
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8
9
10
11
12
13
14
a. Impact surface/groundwater located within
the project area?
b. Have all necessary approvals been
obtained to disturb surface
water/groundwater?
Impact acid sulfate soils located within the
project area?
Generate soil erosion, flooding or salinity
within the project area?
Generate dust?
Generate noise/vibration?
a. Impact Aboriginal Heritage sites located
within the project area?
b. Have all necessary approvals been
obtained to disturb Aboriginal Heritage?
Impact European Heritage sites located
within the project area?
b. Have all necessary approvals been
obtained to disturb Cultural Heritage?
Utility Service Provider (Principal Agency) Declaration
•
•
•
•
•
•
•
•
Utility Service Providers are familiar with Main Roads WA Policy and associated
Guidelines regarding Utility Services in Road Reserves.
Installation, maintenance and management of utility services conform with the current
edition of the Utility Providers Code of Practice for Western Australia (UPCOP);
The Utility Service Provider acknowledges that all necessary environmental and other
statutory approvals have been obtained, particularly related to clearing;
For roads other than declared Control of Access, the Utility Service Provider agrees
to meet the costs of installation and any future maintenance, repair or modification of
the utility service; and Main Roads will consider the merits of seeking a contribution
from the utility service provider towards the cost of a future relocation, should this be
required due to road works, on a case by case basis. In the case of declared Control
of Access road reserves, refer to Note 2, Page 8 below.
The Utility Service Provider undertakes to accept all liability associated with the
installation, repair, maintenance and ongoing operation of the service;
Any damage to Main Roads’ road reserves and assets attributed to the works shall
be immediately restored by the Utility Service Provider to their preconstruction/disturbance condition, to the satisfaction of Main Roads. The worksite
will be left in a clean and tidy pre-construction condition, including revegetation of all
the areas that have been cleared;
The Utility Service Provider agrees to indemnify and keep indemnified the
Commissioner of Main Roads for all damage to any Main Roads’ assets / road
furniture arising from the installation of, or as a result of the presence of, the utility
service;
The Utility Service Provider agrees to indemnify, and keep indemnified, Main Roads
WA, its employees, contractors and agents (but excluding the Utility Service Provider,
its employees, contractors, sub-contractors or agents):
a)
from and against all actions, suits, claims and demands taken, made or
brought by any person against Main Roads WA in respect of:
I) the death or injury of any person; and
II) the loss or damage to property (whether real or personal); and
MAIN ROADS Western Australia
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b)
for the loss of, or any damage to, any property of Main Roads WA, its
employees, contractors, sub-contractors or agents;
in the course of, arising out of, or caused directly by, the works the Utility Service
Provider undertakes under this Application, except to the extent the relevant loss,
damage, injury or death is caused by the negligence of those indemnified.
•
All work will be carried out in accordance with the requirements and information
contained in this Application and relevant legislative and statutory requirements.
Endorsement
I hereby certify that this application contains a true and accurate description of
the proposed works. All works will be carried out in accordance with the
information contained in this application and legislative and statutory
requirements and to any other conditions or specifications imposed by Main
Roads.
Signed: __________________________________________________
Duly authorised officer of the Applicant (Refer Note 1 below)
Name of Signatory: ________________________________________
(PRINT)
Position: ________________________________________________
On behalf of: ____________________________________________
Date: _____ / _____ / _____
Please note that incomplete applications may cause delays. Please refer all
applications and enquires to appropriate Main Roads office. Contact details are listed
in the Attachment 3. Main Roads will advise you in writing of any requirements
to be met.
Main Roads will advise applicants in writing of any requirements to be met.
Note 1: Where the endorsement is made on behalf of the Utility Service Provider (Principal
Agency) a letter from the Principal Agency must be attached to this Application as
confirmation that the Authorised Agent is acting directly on behalf of the Principal Agency.
Note 2: For road reservations declared Control of Access under section 28A of the Main
Roads Act (1930), a Utility Service Management Agreement will be required to be prepared
and submitted by the Utility Service Provider as an attachment to this Application.
MAIN ROADS Western Australia
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PUBLIC NOTIFICATION REQUIREMENTS
ATTACHMENT 2
Applicants must ensure that the text of all media advertisements, announcements,
information leaflets or advanced information signage is approved by Main Roads
prior to issue.
The type of public notification, if required, will be one or more of the following:
•
Placing a display advertisement in The West Australian Early General News section
and the local Community Group Newspaper or Independent Newspaper one week
prior to works commencing. For works exceeding 3 weeks, advertisements may have
to appear in the local newspapers each week following the mandatory initial
advertisements in The West Australian and local newspapers (extent of advertising to
be discussed with the Main Roads Public Affairs Branch). Information details are to
include project description, work cycle period, nature of disruption and contact
information.
•
Arrange radio and TV announcements.
•
Erecting advance information signage on each approach to the work site at least 10
working days prior to start of works but not exceeding 21 working days.
•
Distributing an information leaflet (via a letterbox drop) to all residents and
businesses within the 100 meters of the work site and along any detour routes
required at least seven (7) working days prior to start of the works.
Guidelines for Determining the Method of Public Notification
•
All proposed works that will exceed 4 continuous hours and will result in an
impediment to road users (including motorists, pedestrians, people with disabilities
and cyclists), or results in delays exceeding 15 minutes to the road user, Applicants
may be required to provide notification of such works in the print media.
•
Where the proposed works will exceed 10 continuous hours, either during the day or
night or over three (3) or more days that involve disruption to road users (including
motorists, pedestrians, people with disabilities and cyclists), Applicants may be
required to distribute an information leaflet, install advance information signage and
place advertisements in the print media.
Further information on the type of public notification required can be obtained by contacting
the appropriate Main Roads WA Regional Office shown in Attachment 1.
Lodgement of Advertisements with the Print Media
Applicants are responsible for the lodgement of approved advertisements with the print
media at least 5 working days prior to start of works.
MAIN ROADS Western Australia
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ATTACHMENT 2 (continued)
 Sample Public
Notification Advertisement
ALBANY HIGHWAY
BEDFORDALE
ROADWORKS
Main Roads and Henry Walker wish to advise road users that
works to install an auxiliary lane to the future Narbethong Rd,
Bedfordale and will commence November 1st, 2000 between 7am
and 5pm, Monday to Saturday for approximately three weeks.
Road users should be aware that alternate southbound lanes will
be closed over the works period, however access will maintained
for road users on the southbound lanes.
Road users can expect minimal delays.
Local traffic access will be maintained for road users wishing to
access residences and businesses on and around Albany Highway
at this location.
Road users are urged to slow down when approaching the area,
obey all signs and signals and show courtesy to other road users.
For further information please contact Anton Koekemoer, Henry
Walker Eltin on 9389 4777.
State Gov LOGO MRWA LOGO Company LOGO
Sample Advanced
 Information Signage
MAIN ROADS Western Australia
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MAIN ROADS CONTACTS ATTACHMENT 3
Please direct all enquiries to the Main Roads Customer Information Center on  138
138 or email to enquiries@mainroads.wa.gov.au for Metro Region (ask for the
Customer Services Manager)
For regional office, please visit the Main Roads website contact page:
https://www.mainroads.wa.gov.au/AboutMainRoads/ContactUs/Pages/ContactUs.as
px
(also ask for the Customer Services Manager)
MAIN ROADS Western Australia
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