To:
Highway Authority	Nottingham City Council – Highway Network Management
Email:  highway.management@nottinghamcity.gov.uk	

Applicant		
Address	
	
Telephone		Fax		
E-mail		Contact		
	
Works Promoter		Works Contractor		
	
TM Supplier		Telephone		
	
Emergency Telephone Contact for all hours of lane closure		

Location of Works	

Description of Works	

Description of Lane Closure Arrangements	

Dates of Lane Closure	

Hours Lane Closure will be in place	

	
Works Reference		

Highway Authority use only	HA Reference		
	
Traffic Sensitive	Y		N		Permanent Signals Affected	Y		N		

Lane closure is: (Tick box)	Approved as application		
Approved subject to conditions below		
Conditions / Comments	Not approved as detailed below		

	
	Date	Signed