Road Occupancy Application / Permit - Ontario Public Works & Engineering Department Page 6
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7PUBLIC WORKS & ENGINEERING DEPARTMENT
9 International Drive
Pembroke ON K8A 6W5
Phone: (613) 732-4353 Toll Free: 1-800-273-0183 Fax: (613) 732-0087
After Hours: (613) 735-9930 Toll Free After Hours: 1-866-353-6374
ROAD OCCUPANCY APPLICATION / PERMIT
Planned Work
Emergency Work
Name and Address of Applicant
Applicant’s Name
PO Box and/or Street Address
City/Province/Postal Code
Phone Number
Fax Number
Location of Proposed Work
Estimated Start Date
Estimated Completion Date
Description of Work Being Performed
*A sketch of the work zone must be completed and accompany the application. Please use the
attached “Sketch Form” or attach your own electronic file.
By executing this application, the applicant agrees to all applicable terms and conditions stated in
Policy PW-10 – Road Occupancy Permits, as attached.
APPLICANT’S SIGNATURE
DATE
COUNTY’S APPROVAL SIGNATURE
DATE
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Submit by Email
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