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18) Check with the issuing authority to determine which ofthe /ollowing documents are required to complete the review of your application. <br />a) Property mapindlcadng other access, bordering roads and streets. e) Subdivision, zoning, or development plan. <br />b) Hlgtrxay andddveway plan prorile. f) Proposed access design. <br />c) Drainage plan stowing impact to the highway fight-of-way. g) Pa¢eland ownership maps including easements. <br />d) Map and leRere detailing utility locations betas and after h) TraRk sludles. <br />devekipmentin and along the rightvf-way. i) Praofofownership. <br />1- It is the applicant's responsibility to cooled appropriate agencies and obtain all environmental clearances that apply <br />to their activities. Such clearances may Include Corps of Engineers 404 Permits or Colorado Discharge Permit System <br />permits, or ecological, archeological, historical or cultural resource clearances. The CDOT Environmental Clearances <br />Information Summary presents contact information for agencies administering certain clearances, information about <br />prohibited discharges, and may be obtained from Regional CDOT Utility/Special Use Permft offices or accessed via the <br />CDOT Planning/Construction-Environmental-Guidance webpage hitp://www.dot.state.co.uslenvironmental/Forms.aso. <br />2- All workers within the State Highway right of way shall comply with their employer's safety and health policies/ <br />procedures, and all applicable U.S. Occupational Safely and Health Administration (OSHA) regulations -including, but not <br />limited to the applicable sections of 29 CFR Part 1910 -Occupational Safety and Health Standards and 29 CFR Part 1928 <br />- Safety and Health Regulations for Construction. <br />Personal protective equipment (e.g. head protection, footwear, high visibility apparel, safety glasses, hearing protection, <br />respirators, gloves, etc.) shall be wom as appropriate far the work being performed, and as specified In regulation. At a <br />minimum, all workers in the State Highway right of way, except when in their vehicles, shall wear the following personal <br />protective equipment: High visibility apparel as specified in the Traffic Control provisions of the documentation <br />accompanying the Notice to Proceed related to this permit (at a minimum, ANSI/ISEA 107-1999, class 2); head <br />protection that complies with the ANSI 289.1-1997 standard; and at all construction sites or whenever there is danger of <br />injury to feet, workers shall compy with OSHA's PPE requirements for foot protection per 29 CFR 1910.138, 1926.95, <br />and 1928.98. If required, such footwear shall meet the requirements of ANSI Z41-1999. <br />Where any of the above-referenced ANSI standards have been revised, the most recent version of the standard shall <br />apply. <br />3- The Perrttittee is responsible for compying with the Revised Guidelines that have been adopted by the Access Board <br />under the American Disabil'ttles Act (ADA). These guidelines define traversable slope requirements and prescribe the <br />use of a defined pattern of truncated domes as detectable wamirtgs at street crossings. The new Standards Plans and <br />can be found on the Design and Construction Project Support web page at: <br /><htto://www.dot.state.eo.usNeaign3u on ortA, then click on Design Bul/eKns. <br />If an access permit is issued to you, it will state the terms and conditions for its use. Any changes in the use of the <br />permitted access oat consistent with the terms and conditions listed on the permit may be considered a violation of the <br />permit <br />The applleartt declares under penalty of perjury in the second degree, and any other applicable state or federal <br />laws, that all Information provided on this form and submitted attachments ors to the best of their knowledge <br />true and complete. <br />1 understand receipt of an access permk does not const(tute permission to start access construction work. <br />Applkert's sigrabxe Print name ~ <br /> TON /l - Q -O6 <br />If the applicant is not owner of the property, we require this application also to be signed by the property owner or <br />their legally authorized representative (or other acceptable written evidence). This signature shall constitute agreement <br />with this application by all owners-of-interest unless stated in writing. If a permit is issued, the properly owner, in most <br />cases, will be li as the permittee. <br />Pro er oat Print Ram <br /> ~~~ ~~~ // ~. ~~ <br />C <br /> <br />Pmtoua edillona an oMONta and may not 1M uaee Paaa 2 N 2 CDOT Form M~ 12iaJ <br />