Required fields are marked with asterisks (*)

Highway Use Permit

THIS FORM MUST BE SUBMITTED TEN (10) WORKING DAYS PRIOR TO THE INTENDED START DATE.

Section 1:

Applicant name:

Address:

Phone

Email:

Planned start date:

Planned end date:

I understand the start date MUST be at least 10 business days before scheduled start date

Yes

Project address (Street name):

Description / purpose of work:

Location to/from:

Direction: NB / SB / EB / WB

Nature of closure:

Partial closure

Full closure

Local traffic only

No through traffic

Multiple streets / locations (provide details on Appendix A - Traffic Management Plan)

Number of lanes closed (if applicable):

Will this use disrupt transit routes and stops?

Yes

Start time:

End time:

Mininum requirements:

Prime Contractor Designation
Payment of Fees
Certificate of Insurance
The certificate of insurance needs to state the City of Port Moody as the certificate holder and as the additional insurer at a minimum of $5,000,000
Public Notification
Traffic Management Plan
Coordination with CMBC

Certificate of insurance

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Traffic management plan/sketch or map of location

Browse…

Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Applicant Acknowledgement:

I am the owner of the property.

I agree or disagree with the above statement

Yes

I am the Prime Contractor:

I/we acknowledge, in accordance with the Worker’s Compensation Act (RSBC 1996) Chapter 492, Part 3, Division 3, Section 118 and 119 that I/we are the “Prime Contractor” and are qualified to act as the “Prime Contractor”. I/we accept the duties and responsibilities for coordinator of health and safety in accordance with the Workers Compensation Act. And Further that I/we will do everything that is reasonably practicable to establish and maintain a system or process that will ensure compliance with the Workers Compensation Act and the Occupational Health and Safety Regulations

The prime contractor must comply with the “Traffic Control Manual for Work on Roadways” as well as the Workers’ Compensation Act and Occupational Health Safety Regulations at all times.

Agree

Disagree

Company name:

Contact name:

Company address:

Phone

Fax:

I hereby agree to the terms stipulated herein and further agree to indemnify and save harmless the City against any and all claims, actions or expenses whatsoever or by whomsoever brought against the City by the reason of the City granting us this Highway Use Permit. I further agree to accept responsibility to ensure proper siltation control and street cleaning for the duration of the road obstruction.

I agree or disagree with the above statement

Yes

Collection of information
Personal information is collected by the City of Port Moody pursuant to Section 26 of the British Columbia Freedom of Information and Protection of Privacy Act, R.S.B.C. 1996, c. 165 and will only be used by authorized City staff for the purposes of operating the myPortMoody program and providing the services available through the myPortMoody portal. Questions regarding this collection of information can be directed to the City’s Legislative Services department by email at FOI@portmoody.ca or mail at 100 Newport Drive, Port Moody, B.C. V3H 5C9.

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Highway Use Permit