PIA & Civils A55 - Region 4

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location

• Is there a blockage?

  Yes

  No

  N/A

• Provide a photo of marked up area (including surrounding area)

  Media

• Is the blockage at a pole base or duct mouth inside a chamber?

  Yes

  No

  N/A

• Provide a photo of the marked up area?

  Media

• Is the blockage on private land?

  Yes

  No

  N/A

• Do you have temporary markers if landowner refuses the use of spray paint?

  Yes

  No

  N/A

• Is the blockage over 3m - if so both locations must be photographed and raised separately.

  Yes

  No

  N/A

• I can confirm these will be processed as a double blockage and photographed seperately

• Has the blockage been proved at both ends? - Rod must be photographed at both ends

  Yes

  No

  N/A

• Have photographs of the overview of the surrounding structure been taken?

  Yes

  No

  N/A

• Provide measurements from both structures rodded to blockage location

• Provide measurements of total duct length to avoid discrepancies

• Provide Chamber numbers for all chambers along the route

Civils

• Is this Greenfield?

  Yes

  No

  N/A

• Provide detailed description of Civils works required.

• Is traffic Management required?

  Yes

  No

  N/A

• Is parking available on site? (provide a description of any restrictions)

• Is there more than one property involved?

  Yes

  No

  N/A

• This requires a Construction Survey - this must be sent back for completion.

• Provide photos of start point and end point

  Media

• Provide clear measurements between Chamber/Toby/Property (Include all chamber numbers)

• What surface is currently in place? (this must be for the full length of the civils required, including change in surfaces)

• Provide clear photos of overview of the civils (showing start & end point where possible)

  Media

• Provide photos of marked up lines

  Media

• Provide a description of the route agreed

• Does a permission to dig need to be obtained?

  Yes

  No

  N/A

Permission to Dig

• Before Jurassic Fibre can provide/restore/rectify service and/or infrastructure, permission is required to

  Select Excavate on Private Property Drill through external walls Drill through floors Small Garden landscaping Access to work on existing infrastructure Other

  • Excavate on Private Property
  • Drill through external walls
  • Drill through floors
  • Small Garden landscaping
  • Access to work on existing infrastructure
  • Other

• The reason for permission?

  Select Clearing existing infrastructure Uplifting Other

  • Clearing existing infrastructure
  • Uplifting
  • Other

• The work to be carried out has been explained to me?

  Yes

  No

  N/A

• I wish to be present when the work is carried out?

  Yes

  No

  N/A

• NB: Our approved contractors are fully licensed and follow NJUG and HAUQ specifications for reinstatement. They will carry out this work at the expense of Jurassic Fibre, unless the work is to rectify damage caused by tenant/landowner, or any contractor they have employed, in which case you may be charged. When reinstating excavated surfaces (carriageway or footway) neither Jurassic Fibre or suppliers can guarantee a perfect match to the original surface due to the effects of age and weathering. Jurassic Fibre and suppliers will however take all reasonable care to reinstate the surface to your satisfaction

• JFL Engineer Name & Signature

  Sign

• JFL to date

  Date

• Customer Name & Signature

  Sign

• Customer to date

  Date

• Authorisation Signature (on behalf of Legal Landowner)

  Sign

• if it is tree cutting, TM, pole related, scaffolding

  Yes

  No

  N/A

Completed by

• Add signature

  Sign