Traffic Authority Reference
Works Reference Number[Incl. Prefix]
Works Notice Submission Date / DD-MM-YYYY
Restriction Application Date / DD-MM-YYYY

Appendix A-1

FORM TR-1 Part 1:

APPLICATION FOR A TEMPORARY RESTRICTION

Applicant Details

Applicant Name:
(will appear in notice) / Contact Number:
(may appear in notice/order)
Company Name:
(will appear in notice)
Company Address:
On Behalf of:
(will appear in notice) / If works are for a statutory organisation, name them here
Invoice Address: / Purchase Order Number:

In making this application the applicant named above:

  1. Agrees to pay the charge associated with the restriction as set out in the authorities schedule of fees/rates
  2. Agrees to fulfil the Standard Conditions as set out in the guidance.
  3. Recognises that the Authority may impose Additional Conditions specific to this particular application.

Reason for Restriction

Type of Restriction: / Restriction
Specify, Closure, Weight, Height, Speed, Parking etc / Emergency/OtherEmergencyOther*
Description of Activity:
Justification for Restriction: / Must identify why the restriction is necessary

Location of Restriction

Street Name/Descriptor / text / text
Locality / text / text
Town / text / text
USRN from NSG / number / number

Extent of Restriction [A Plan must be provided on Form TR-1 Part 2]

Street Centreline Co-ordinates / Start Eastings / Start Northings / End Eastings / End Northings
Description of Extent / [see plan attached]
Emergency Vehicle Access Provisions
Pedestrian Access Provision
[Check 1 box only] / Pedestrian access to all properties within the restriction will be maintained along defined routes throughout the period of closure.
Pedestrian access to all properties within the restriction and access through the restriction will be maintained along defined routes throughout the period of closure.

Period[s] of restriction to be imposed

Period Number / Start Date / Start Time / End Date / End Time
1 / : / :
2 / : / :
3 / : / :
4 / : / :
Works Reference Number:

FORM TR-1 Part 2

LOCATION AND EXTENTS PLAN

PROPOSED DIVERSION ROUTE[Scale - 1:50,000 OR LESS]

Guidance to Applicants 2009-01-20.doc