Temporary Traffic Signal Permit Application

Section A
Application for the use of Portable Traffic Signals
Please note that you must have the road space booked, and provide us with your SRWR LAREF Number or Permission Application Number, prior to applying for the portable traffic signal permit.
If you do not have already have the road space booked and require a road occupation permit / road opening permit / or permission to execute road works please complete the required forms prior to completing this form.
I have read and understood the conditions in the Traffic Signal Permit Conditions
YesNo
Request permission from the Roads Authority for the use of 2 way portable light signals and to request confirmation that specific site approval is NOT required
YesNo

Section C
Location of Works
Location of Works - Address
City
County
OS Grid Reference
Traffic Sensitive?
YesNo
Please upload an Ordinance Survey plan indicating the work area and traffic control arrangements.
Purpose of works
Are these works urgent?
YesNo
Works carried out FROM (date)
Works being carried out FROM (time)

Hours

Minutes

Seconds

AM/PM
Works carried out TO (date)
Works being carried out TO (time)

Hours

Minutes

Seconds

AM/PM
Proposed signal operation
Working Day24 HoursNightOff Peak
Remarks

Section E - Declaration
I agree to meet all reasonable costs incurred by the Roads Authority in respect of the connection, operation and disconnection of the signals and in respect of giving emergency attention in the event that the 'emergency contacts' cannot be reached or are unable to rectify any fault within 2 hours of the first notification that the signals or associated signing are faulty. It should be noted that the Roads Authority and its employees in no way accept responsibility for any claims or demands which may be brought against it by third parties in any way by virtue of the installation operation or emergency rectification of these signals.
Declaration - Name

First name

Last name
On behalf of
Date (dd/mm/yyyy)
Application must not be taken as approval

Temporary Traffic Signal Permit