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t ei Crw:�.�-^,itw ic:�.�n��;�mmry m 4e�ertnne wncti Cr:'tt+'�.�L3wlny duwr�L�ro•oairwc:to m�iet?;'+P r!'.'�Pr!3t yC�uf ePC11Ca'b)n. <br /> aj PfoDerty R18D rv'�ii.;yGry aUwr acLoa.c.barcl�►rxx�rcacls etnd SUpe�. a, :,i�..rv�onn zorong or deve:�prnent�&r; <br /> � i-Iit�rway anc!crn�ewaY R�M 0��'1e. Q Rropo-od,r,-n��da�gn <br /> CI �3�n�c olan fiowirq rnpart m 1"�s haDlw�aY rWM-�t-r�dV. p� n9i CH srW ir+nersttiP rtwP:'ncludng aa^.omors- <br /> dl M!�8M ItttP'E tl2Winr�utiuy IocaCona b�icta:�d�ttar �i I rt�"i�C L:.1Wei. <br /> dar,�a�ent n en;alc�g the ngM-uI•�ay. � xocf r�to��.�hc. <br /> t tt is the appiicant s responsih+liiy to contsr.t a�oprtats agencies and obiain alt emimnmental cl9a�ancss that apply t� <br /> thair activdie�. Such clearances may includc Corps of Engrneers aUd Permits or Cdcrado Disct��gc Parmit Sy�tem <br /> pormrts, or e;,alogical, archeolo9ical, histoncal or cuttura! resouroe dearances. The CDOT Emaronmantal qearances <br /> �ntormatwn Surremary p�esents contaci informaUon tar a9encies administering certain doarances. �niarmation about <br /> prchibited discharges, and may bo abtained bom Fiegionat CDOT(hilitylSpecial U:,c Pcrmit offices or acoessed»a the <br /> COOT Ptannirq,�Cor�smjc�on-Environmental-Ga,r�ance ,+rebpagc: httas:llwww.codoLaovlprogramslenviro�rU <br /> resourc�sl�uidance-stanclards�environmental-clearances-info-summarv-auaust-2Dt 7lview <br /> 2- AI!vrorker5 within the Si�t�Highway right of w�y ghal) Gpmply with their employer's safety anri h�lth pc>lirjgs;' <br /> procedura�,and all appli��U.S.Occup�ational SafAiy and Health Admirtistration(OSHA)regulations-including, but not <br /> Eimited to thc anplscable secGons af 29 CFR Part 19t0-Occupataanal Safety and Heatlh Stsndara�and 29 CFR Part i926 <br /> -Safety�nd HCalth Regvtatiorts(or CanstrtiCtion. <br /> Personal proteclive equipmeM te.g. head prateciian, toocwear, high visibikty apparel,safery gla;�es, haarinq prolection, <br /> respirators,9bves,etc.l shall be wom��apprapriate tor the worfc beiny perfom�ed.�nd as spotifwed in regulation. At a <br /> rn,ntmum,a�v►erkers in thc State Nighway reght ot way.ex�pt when in their vchictcs,sh�ill wear the tollowing personat <br /> protective equipment: High vi�ibility apparel as:�pecitied in the Traffic Control provis+ons of the documcntalion <br /> afloomp�anyin9 the NoDc�to Proceed related[o lhis permit f,at a minimum,ANSIr1SEA 107•l999.Gass 2}:head protectian <br /> that Complies wittt Ihe ANSI Z89.t-�997 starxiard;and at aa o0nstruction Sites or whenCVCr there is danqor o1 mjury io <br /> feet: worke�s shsil comply with OSHA s PPE requirements for fopt protection per 29 CFR 19s 0.136. 1926.95.and <br /> 1926.96_ Ii r��ired,such footvr^ear shall meet the req�rements oi ANSI Z41-1ggg- <br /> Whe�re any ot the above-referenced ANSI sk�ndards have been revi,�d,the most recent version of the sta�dard sha�l <br /> apply_ <br /> 3- The Permittee is respo�sible for oomplyinp with ti�e Rev�sed Gutdelines Ihat have been adopted by the access Baard <br /> under the American Disabi�itiss Act(ADA). These guidelines defrne traversabfe slope requiremerns and�escribe the use <br /> vt a defrr�d patiam of tnmcated domes as deteclable waminys at street crowinQs. The new Standard;Plans and can be <br /> found on tho Design and ConsirvUron Projec[S�uppsxt�veb pape at: <br /> httFs:!lwww.todotaov/businesslcivilrightsladatresources�en9 inee►s <br /> if an a�oeas permit i�i��ued to yott,it will stato the tsrms and condi�ons for its use.My changes�n the use oi tt�e <br /> permitted aocess no4 can.�istern with the tcrms 1nd conditions listed an the permil may be cortsidered a violation ai tt�e <br /> permit. <br /> The ap licartt declares under psnalty ot perJury M the second degree,and any otf�►er applicabk state or tederal <br /> e <br /> laws,t all tMormatiat provided on this torm and s�bmitted attachmerns are to the best of their kr►ow�edge <br /> true and comple�te_ <br /> I understand reoeipt Of an accesg permit dpes not constitute permission to start a�ess co�struction work. <br /> __—___ _ <br /> �pGM9�tt Of.�Qlrtt ,W NE�TT�ItOP�E&6R8,'Jfe � -- '.�Pnnt rur�a �Lb1c <br /> � <br /> If the appliCant is noi the cwner of Ihe pcoperty.we rectuerr lhis applicalaon also to be agned by the property owner or <br /> their legaily authorized representative {Qr other acceptable writfen evidence).�t�s siynature sha11 constitute ayreement <br /> with this applicaUon by alf owners-ai-iMerest unless stated in wRtir�. If a permit is issued,the{xoperty awner, in most <br /> cases, will be ti��as the permittcc. <br /> _._---- . <br /> ProCe^f �ner s+�aT�re ' �Pnrr,neme _ _ _ <br /> ;I]nh� <br /> .��L: ! r/��/��l <br /> � !' (�►r h • - <br /> vrr.�ou..adoe.n.e6sa.a.�a.n.y na n.w.a as0.2 a t cooT Fo.r�Kts7 tz9s <br />