Works within a road reserve
Date:
/
For works on nature strip ONLY (GL14)
CSO to issue – Consent No. _____________
50 km/hr or lower – fee of $81.60
60 km/hr or higher – fee of $319.60
/20
Type:
Application for consent (fee payable)
Notification of completed works
For all other works (GL14)
(Consent to be issued by Engineering Services)
50 km/hr or lower – fee of $319.60
60 km/hr or higher – fee of $586.20
Engineering Services
Old Calder Highway
Keilor Victoria 3036
T 9249 4430
F 9249 4351
W brimbank.vic.gov.au
E info@brimbank.vic.gov.au
Applicant details
Utility or agent
Telecommunications Carrier or agent
Road Authority
Other (e.g. builder, plumber, property owner)
Name:
Address:
Suburb:
Postcode:
Contact:
E-mail:
Telephone:
BH
Mob/AH
Fax
Details of work
Type
Service/utility connection
Work hours from:
:
/
Start date:
Drainage connection
am / pm
/20
Other works (provide full description below)
to
:
End date:
Address of works:
/
am / pm
/20
Speed Limit:
km
Suburb:
Description of work
(Attach a copy of a sketch plan showing the location of proposed works and detailing all assets within the vicinity
of works ‘Assets’ includes all trees, landscaping, road pavement, kerb & channel, footpaths, drains, utility/services assets and private assets)
Works Manager details
(the person or body who was/will be responsible for conducting these works)
Note: Please attach a copy of the current Certificate of Currency for Public Liability insurance with a minimum value of $10
million dollars and complete the attached Form of Indemnity. Consent will not be issued without these documents.
Company name:
ABN:
Address:
City/town:
Postcode:
Works Manager name:
E-mail:
Telephone:
BH
Mob/AH
Temporary reinstatement details
Required?:
Details
Yes
No
End date
Fax
(not required for Notification of Completed Works)
/
/20
(attach additional pages if required)
Engineering Services
July 2015 | Revision 10
REC.ENG.023 - Page 1 of 3
Permanent reinstatement carried out by:
Company name:
Address:
City/town:
Postcode:
Contact:
E-mail:
Telephone:
BH
Traffic impact
(not required for Notification of Completed Works)
1.
Mob/AH
Fax
Will a Traffic Management Plan be in operation during the proposed works?
Yes
No
(Note: refer §99A of the Road Safety Act 1986 and Code of Practice for Worksite Safety – Traffic Management)
2.
Will major traffic control devices requiring a “Memorandum of Consent” be used?
Yes
No
Examples of major traffic control devices include speed limit signs, traffic signals (including portable traffic signals, etc)
Note: refer Road Safety (Road Rules) Regulations 1999 and Code of Practice for Worksite Safety – Traffic Management
3.
Will the works:
a. Require deviation of vehicular traffic on-coming traffic lane?
b. Be conducted in a clearway when in operation?
c. Be conducted on, partly on, or affect a bridge or other structure?
Yes
Yes
Yes
No
No
No
4.
Will closure of the road or part of the road to vehicular traffic be required for:
a. A continuous period of more than 12 hours?:
b. More than 24 hour in a 7 day period?
Yes
Yes
No
No
5.
If “Yes” to either 4(a) or 4(b), then what is:
a. The number of traffic lanes to be closed?
b. The length of traffic lane to be closed (1st lane)
c. The length of traffic lane to be closed (2nd lane)
6.
Please provide any other relevant traffic information, including impact on pedestrians (including provision for people
with disabilities, cyclists and public transport)
(attach additional pages if needed)
Consultation
____________
___________ m
___________ m
(not required for Notification of Completed Works)
Have you consulted with adjoining property owner(s)/occupier(s) and/or affected members of the community?
Date:
Mitigation plan
/
/20
Is access affected?
Yes
No
Yes
No
(attach additional pages if needed)
Assets of other Parties/Authorities affected
(not required for Notification of Completed Works)
(type of assets affected includes other utility infrastructure, street trees, remnant vegetation and landscaped areas)
Owner:
Consulted?
Asset:
Effect:
Minimisation plan
Consulted?
Asset:
Effect:
Engineering Services
No
Yes
No
(attach additional pages if needed)
Owner:
Minimisation plan
Yes
(attach additional pages if needed)
July 2015 | Revision 10
REC.ENG.023 - Page 2 of 3
Payment Options:
Payment In Person
Payment by mail
Present this form and relevant documentation with your
payment at one of the following Customer Service Centres:
Please attach this form and relevant documentation to your
payment and post to:

Sunshine – Alexandra Avenue, Sunshine
Mon – Fri, 8.45am - 5pm

Keilor – 704B Old Calder Highway, Keilor
Mon – Fri, 8.45am - 5pm

Watergardens – Station Street, Watergardens
Town Centre, Taylors Lakes
Mon, Wed, Thurs, 10.30am - 7pm. Tues, 1pm - 7pm.
Fri, 10am - 5pm. Sat, 10am - 12.30pm
Engineering Services
(money order or cheque, NO CASH)
Brimbank City Council
PO Box 70
Sunshine 3020
July 2015 | Revision 10
REC.ENG.023 - Page 3 of 3