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COLORADO DEPARTMENT OF TRANSPORTATION Issuing authority application <br /> STATE HIGHWAY ACCESS PERMIT APPLICATION acceptance date: <br /> Instructions: - Contact the Colorado Department of Transportation(CDOT)or your local government to determine your issuing authority. <br /> - Contact the issuing authority to determine what plans and other documents are required to be submitted with your application. <br /> - Complete this form(some questions may not apply to you)and attach all necessary documents and Submit it to the issuing authority. <br /> Please print - Submit an application for each access affected. <br /> or type - If you have any questions contact the issuing authority. <br /> - For additional information see CDOT's Access Management website at hftpJ/www.dot.state.co.usiAccessPermits/index.htm <br /> 1)Property owner(Permittee) 2)Applicant or Agent for permittee (if different from property owner) <br /> Street address Mailing address <br /> City,state&zip Phone# City,state&zip Phone#(required) <br /> r - ��, � 71�t 71 <br /> E-mail address E-mail address if available <br /> 7W�4 t <br /> 3)Address of property to be ed by permit(required) <br /> 4)Legal description of property:If vftin jurisdictional lim's of Municipality,city and/or County,which one? <br /> county subdivision block lot section, tolmship <br /> 90 i S <br /> 5)What State Highway are you requesting access from?, 6)What side of the hi hway? <br /> 1,U N S E W <br /> 7)How many feet is the proposed access from the nearest miI4 post? How many feet is the proposed access from the nearest cross street? <br /> _ feet(]NOS❑E from: aN S❑E )from: L ct S <br /> 8)What is the approximate date you intend to begin construction? <br /> i) ;�U_'), <br /> 9)Check here if you are requesting a: <br /> 0 new access Qtemporary access(duration anticipated: ) Qimprovement to existing access <br /> change in access use Dremoval of access Oelocation of an existing access(provide detail) <br /> 10)Provide existing property use <br /> / l: <br /> 11)Do you have knowledge of any State Highway access permits serving this property,or adjacent properties in which you have a property interest? <br /> �no Dyes,if yes-what are the permit number(s)and provide copies: and/or,permit date: <br /> 12)Does the property owner own or have any interests in any adjacent property? <br /> Pno ®yes,if yes-please describe: <br /> 13)Are there other existing or dedicated public streets,roads,highways or access easements bordering or within the property? <br /> 7P no ❑yes,if yes-list them on your plans and indicate the proposed and existing access points. <br /> 14)If you are requesting agricultural field access-how many acres will the access serve? <br /> .111e) <br /> 15)If you are requesting commercial or industrial access please indicate the types and number of businesses and provide the floor area square footage of each. <br /> business/land use square footage business square footage <br /> 16)If you are requesting residential developement access,what is the type(single family,apartment,townhouse)and number of units? <br /> type number of units type number of units <br /> 17)Provide the following vehicle count estimates for vehicles that will use the access.Leaving the property then returning is two counts. <br /> Indicate if your counts are he r%nqq #of passenger cars and light tricks at peak hour volumes #of multi unit trucks at peak tour volumes <br /> eak hour volumes or average daily voluMes. 1 <br /> #of single unit vehicles in excess of 30 HL #of farm vehicles(field equipment) Total count of all vehicles <br /> -�- 0 <br /> Previous editions are obsolete and may not be used Page 1 of 2 CDOT Form#137 01/10 <br />