CONTRACTORS NOMINATED SITE SUPERVISOR AND OPERATIVE (NEW ROADS AND STREET WORKS ACT 1991) SWL4

To accompany Street Works Licence application for placing apparatus in the highway or application for consent to work on existing apparatus (To be completed by the contractor) Please see the Notes for Guidance which requires Adobe Acrobat reader

Details of Proposed Works

*	Road/Street
*	Town/Village
*	Property/Development
	Nature of Works

Contractor Details

Company

ACCREDITED SUPERVISOR

	Accredited Supervisor Name
	National Registration Number
	Date of Birth
	National Registration Number

ACCREDITED OPERATIVE

	Accredited Operative Name
	National Registration Number
	Date of Birth
	National Registration Number

Signature Please complete if printing this form.

Signed ............................................................................... Name................................................................................. Date...................................................................................