WORKS WITHIN ROAD RESERVE APPLICATION
This notification / application is provided in accordance with –
1. Road Management Act 2004, Schedule 7
2. Road Management (Works and Infrastructure) Regulations 2005
3. General Local Law No 7 (2005)
COUNCIL SPECIFIC INFORMATION
Shire of Campaspe: Contact us +61 03 5481 2200 http://www.campaspe.vic.gov.au PO Box 35 ECHUCA VIC 3564
Please use this form to apply to the Shire of Campaspe to obtain consent / permit to occupy or undertake works in, on or under the road reserve or
notification of completion (utility authorities only)
Fields marked with and asterisk (*) and must be completed.
Once form is completed, please print, obtain relevant signatures and forward to Council
GENERAL INFORMATION
Purpose of Application * (Please tick applicable)
Notification of Proposed Works
Application for Permit to Work Within Road Reserve
Notification of Completed Works
Date: *
Permit Number:
Your Reference:
APPLICANT DETAILS:
Applicants Role:
(Please tick applicable)*
Name Applicant:
Owner
Builder
Title *
Signature
Occupier
Contractor
Surname*
Given Name/s*
DETAILS OF BUISNESS UNDERTAKING WORKS:
Details of Business
Undertaking Works
Insurance Details
Business Name*
Work Manager*
Address*
Town / Locality*
Post Code*
Phone (BH) *
Mobile Phone*
Email
Details*
(Attach copy of current Public
Liability Insurance)
Minimum value of policy to be 10 million dollars ($10,000,000)
(If different from property owner)
Contact Details
(At least one phone number must be
provided)
DETAILS OF WORKS:
Start Date:*
Location of Work:
Work Type:
Street Address *
Town / Locality *
ABN:
End Date:*
Vic Roads Country
Directory:
Edition No*
Map No*
Grid Ref*
Type of Work* -- insert selection --
(Select from list)*
PROPERTY DETAILS (If Applicable):
Name Property Owner/s:
Title *
Surname*
Signature*
Property Address:
Street Address*
(Location of Works)
Town / Locality*
Post Code*
Contact Details
Phone (AH)*
(At least one phone number must be
Phone (BH)*
provided)
Mobile Phone*
IMPACT OF WORKS
Area of road reserve (kerb,
path, pavement) and other
assets that may be affected
(fencing, bins, signs, bus shelter)
(Select from list)*
Given Name/s*
Area of Road Reserve involved* --- insert selection --- and --- insert selection --Assets that may be affected* --- insert selection ---
*Please ensure that all sections of this form are completed
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Location of Utility Assets in
Close Proximity to Works:
Utility assets in view of works*
Description of Works:
Details*
(Dial Before You Dig)
(Include risk assessment and risk
mitigation measures, as well as the
description of the proposed works)
(Attach sketch of proposed works)
REINSTATEMENT
Estimated End Date for permanent reinstatement of works*
(When will works be completed and returned to original condition)
Details of reinstatement works to be carried out*
Note: Applicant is responsible until works completion notification is made to Council and works accepted.
(Refer Standard Drawing for minimum reinstatement requirements)
Are reinstatement works to be conducted be a contractor on behalf of the Works Manager?*
Yes
CONSULTATION
Have you consulted with adjoining property owners) / occupiers(s) and / or affected members of the community?
Date consulted:
Yes
Will access to the adjoining properties be affected?
Yes
Mitigation Plan (Describe your proposed plan to minimise any adverse effect on adjoining properties)
Details:
No
No
No
AFFECTED ASSETS
Asset #1
Name of Organisation that owns or manages other assets that may be affected by the works*
Details of Organisation:
Have they been consulted?
Assets affected (e.g. utility infrastructure, street trees, remnant vegetation and landscaped areas)
Detail:
Yes
No
Effects on the assets
Detail:
Mitigation plan
Detail:
Additional Assets Affected
List other organization(s) that own or manage other assets that may be affected by the works.
(Attach details of additional affected assets)
FEES
Refer to the “Works Within a Road Reserve Permit Fees” based on the Units prescribed by Road Management (Works & Infrastructure) Regulations
2005 and fees prescribed by the Monetary Units Act 2004
ACKNOWLEDGEMENT
I understand and acknowledge that:
 The information provided in this application is true and complete to the best of my knowledge
 This application forms a legal document and penalties exist for providing false information
 The works are to be guaranteed for 12 months following completion
Name of person completing this application:
Signature of person completing this application:
*Please ensure that all sections of this form are completed
Date:
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DOCUMENTS TO SUPPORT APPLICATION
The following matters must be addressed and evidence provided to Council prior processing and issuing A Works Within Road Reserve Permit.
1. Traffic Management with consideration of:
 Pedestrian movements
 Emergency Services
 Will a Traffic Management Plan be in operation during the works?
Yes
No
 Will major traffic control devices requiring a “Memorandum of Authority” be used?
Yes
No
Examples of major traffic control devices include speed limits signs and traffic signs (including portable traffic signals)
2.
3.
4.
5.
6.
7.
 Copy of the Traffic Management Plan must be attached
 Note: The TMP must be prepared by a competent traffic manager and must comply with requirements of the Road Safety (Traffic
Management) Regulations 2009 and be onsite at all times during works. Responsibility for traffic management remains with the site works
manager but the worksite may be inspected by Council Officers for compliance with the TMP.
Site Plan – Include a scaled location map showing the location of utility assets, which road and which part(s) of the road reserve is affected,
proposed depth of cover, clearance and offsets to other road and non-road infrastructure.
Consideration of native vegetation, flora and fauna and pest plants. If in a listed area the application will be referred to Councils Conservation
Officer, on receipt of the application.
Property owner approval on application (when the work relates to a property)
Section 173 Agreements as per Council Policy 132 – Private Water Assets in Road Reserves (when required for installation of some infrastructure
in road reserves). Council Officers will progress on receipt of the application.
Dial Before You Dig for all works must be acquired and copies provided to Council. (Note some utilities do not subscribe to Dial Before You Dig)
Council approval for engineering works which may affect road infrastructure or public safety including drainage. Council will require works which
form part of the road infrastructure to be built to Council standards. Construction must be in accordance with standard drawings and inspections
during construction may be included as part of the permit requirements.
Refer to the Infrastructure Design Manual – www.designmanual.com.au
 SD 205 Typical Footpath Detail
 SD 255 Typical Swale Drain Vehicle Crossing (Rural Entrance)
 SD 210 Typical Footpath Joints
 SD 260 Typical Swale Drain Vehicle Crossing (Fringe Urban
Entrance)
 SD 235 Residential Crossing Retro Fit
 SD 265 Typical B Double Vehicle Crossing (Rural Entrance)
 SD 240 New Residential Crossing Single
 SD WCC-21 Trenching Backfill
 SD 245 New Residential Crossing Double
 SD 250 New Industrial Crossing
ADVICE ONLY
The following documents / permits or notification may also be required when undertaking the proposed works. Issuing a “Works Within Road Reserve
Permit” does not address the requirements of the following matters, these remain the responsibility of the applicant:
 Planning Permit, when required. Refer to Council’s Planning Department for clarification
 Building Permit, when required. Refer to Council’s Building Department for clarification
 Cultural Heritage Management issues
 Catchment Management Authority
 Parks Victoria
 Environmental Protection Authority
 Emergency Services
 Department of Sustainability & Environment
 Rail Authority
 Adjoining Municipality
 State Border and Murray River matters
 Worksafe requirement – including risk assessment
PRIVACY STATEMENT
The information gathered in the form is used by Council to process the application. To view Council’s privacy policy, please either visit a Council Office
of go to Councils website www.campaspe.vic.gov.au and search Councils Information Privacy Policy #81
LODGEMENT If you intend to post , email or fax this form, please use the details provided below:
Shire of Campaspe
PO Box 35
ECHUCA VIC 3564
*Please ensure that all sections of this form are completed
Telephone: 03 5481 2200
Fax: 03 5481 2290
Emails: shire@campaspe.vic.gov.au
Web: www.campaspe.vic.gov.au
Created on 11/29/2012 8:50:00 AM
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