App ES caffdand Hoard Application Form

							                                                                                                                                             Appendix E          Guidance Notes and Examples (This page won't print)


                                                                       Application to Place Scaffolding or Hoarding on the Public Highway                        This is the Staffordshire Highways standard proforma for applying to place scaffold or hoarding on the public highway. Any queries, please
                                                                                                                                                                 contact the Network Management Unit on 01785 276784
                                                                                            ALL FIELDS MUST BE COMPLETED
APPLICANTS DETAILS
(Owner of the scaffold / hoarding)
Organisation Name                                                                                                                                                Name of the organisation which owns, erects, dismantles and is responsible for the scaffold / hoarding.
Organisation Address




Telephone no.                                                                                                                                                    No. of direct contact - this number should be a direct line or mobile and will not be shared publicly but for internal purposes only.
Fax no.                                                                                                                                                          Permit will be sent to this number
Emergency contact name & no. (24hr)                                                                                                                              Emergency contact for highways staff should an issue arise on site both in hours and out of hours
Your internal job reference no.                                                                                                                                  Your internal reference number / job number (which will appear on invoices)

DETAILS OF PERSON(S) RESPONSIBLE ON THE
SITE WHERE THE SCAFFOLD / HOARDING IS TO
BE USED
(Customer requesting the scaffold/hoarding)

Name                                                                                                                                                             Name of the Customer who has requested the scaffold / hoarding.
Address                                                                                                                                                          Address of the customer. This can be different to the location of the scaffold / hoarding in some cases but if not, please enter 'as location'.




Telephone no.                                                                                                                                                    Customer contact number. This is required should an issue arise relating to the work or activity as opposed to the scaffold / hoarding itself.
Fax no.
Emergency contact name & no. (24hr)                                                                                                                              Emergency contact for highways staff should an issue arise on site both in hours and out of hours
LOCATION DETAILS
Outside/Opposite:                                                                                                                                                Location of where the scaffold / hoarding is required for e.g. Outside 54.
Full address:                                                                                                                                                    Full address of the location the scaffold / hoarding is required.




Position of base of in the Highway:                                    Carriageway        Footway                Verge                                (circle)   Please confirm where the base of the scaffold / hoarding will be on the highway (circle relevant)
Length of scaffold / hoarding (m, along the highway):                                                                                                            Length in metres that the scaffold / hoarding will occupy along the highway (i.e. length aqdjacent the property, parallel to the kerb/carriageway)
Height of scaffold / hoarding (m, above the highway):                                                                                                            Height in metres (can be approximate) of the scaffold / hoarding above the highway (i.e. vertical height from ground level)
Width of scaffold / hoarding (m, across the highway):                                                                                                            Width in metres that the scaffold / hoarding will occupy across the highway (for e.g. from kerb to property)
NATURE OF REQUIREMENT

Nature of work / activity for which the scaffold/hoarding is
                                                                                                                                                                 Brief detail of the works or activity for which the scaffold / hoarding is required for e.g. roof replacement
required:

Is this an extension to an existing permit?                                                                Previous Permit No.                                   Is this an extension to an existing permit? If so, please quote original permit no.
Proposed dates of use:                                         From:                                       To:                                                   Proposed dates of use. Please note that permitted dates may be different to those you propose
In place for 24hrs a day?                                                                                                                                        Will the item remain on the highway for 24 hours a day? Yes or No.
If no, proposed hrs:                                           From:                                       To:                                                   If not in place for 24hrs a day, please state times of proposed use. Please note that permitted times may be different to those you propose if the road is traffic sensitive.

          The applicant MUST be a registered organisation - contact the Network Management Unit for a registration form if not completed previously

This application MUST be signed by an authorised representive of the organisation applying. The signature of this representative is taken as confirmation
that all standard conditions have been read, understood and will be adhered to. By signing, this representative confirms that the Network Management Unit
Licensing and Permissions Policy and Guidance Document and all associated legislation and guidance is understood.

Signature of Applicant:                                                                                           Date:
Printed Name of Applicant:

Completed forms should be sent to the Network Management Unit:

E-mail:                                                        nmu@staffordshire.gov.uk

Fax:                                                           01785 854037