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COLORADO DEPARTMENT OF TRANSPORTATION cwahlr~,ry - DAPir~ Tie <br />UTILITY PERMIT ~^^^~^ .. = ~~°~"~'" <br /> Standad we- M <br />PERMITTE€24th Estates P3YtneYS DEPARTMEN7(,ISE(l~i4Y2 <br />U / ~ 1 / U <br />Name Date Issued <br /> Permit# <br />Address ' ' S.H: # M.P. ' <br />' DisMct <br /> Section <br />Telephone Patrol <br /> <br />NOTICE TO PERMITTEE: You must notlty owners or operators of urWergrountl utlliry fadlitles et least Ixo (2) Wslness days prtor [o maltlng or bepinning exnavatlona In are Ndnlry of <br />such facAitlea, es requiretl under Section &1.(i1a3, Coorado Revisetl Statutes. CALL UTILITY NOTIFICATION CENTER OF COLORADO (UNCC), 1-800-822-1&97, OR 539$7001N <br />METRO DENVER, FOR MARKING OF MEMBER UTIDTIES. CONTACT NON-MEMBER UTILITIES DIRECTLY. <br />ACTIVITY DESCRIPTION: (famished by Permittee) <br />PURPOSE ^ Installatlon O AdjustrnenVRelocation ^ Removal ^ Malntenanc~nfe>~s~r)g~fpcil~t)hlet and widening for <br />FACII~'(~7~~I~T,adL,lz~~~~'lt~,~gsl~rtp1a~repr~t~al, e[e,) °Y <br />MATURE OF INSTALLATION ^ Longitudinal (Parallel) O Transverse (Crossing) <br />^ Buried' O AeriaVGround-mt~reted O Attach.toHwy.~~~~9 eernme~ee~i1=~--- <br />LocnnoN state Hwy. No. 1~4fY)A'h e€ 128th: Ate-and--~?~5r <br />fu4lepdnt(s) a intersecting feature(s) <br />ADDITIONAL REMARKS <br />'For underground rotation Inforrnatlon, contact: _ } $8$-9$$ } ~ -) <br />Telephone <br />PLANS: Attach plans or work sketch ("EXHIBIT A`) showing locatlon, character, dimensions, and details of the work to be done. 4 sets minimum <br />required. Compliance with the plans or sketch, as approved by the Department, shall be a condition of this permit <br />SPECIAL PROVISIONS (completed by the Department) The Special Provlslons are terms and conditions of this perntt. <br />Any work shall onty be in acwrdartce with the approved plans, Standard Provisions, and Special Provisons as set fodh in this permit <br />rnecoorinspilctoris Greg Sinn Telephone 303-916-0463 <br />Work ro be completed on or before: j I )8 O z <br />Worktime restrictions: <br />Designated Minimum cover is .Designated minimum overhead clearance Is <br />Pavement cuts permitted onty as follows: <br />Replace pavement to the following spedfications: <br /> <br />Required location olds (burled fadlities): <br /> <br />OTHER: <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Permitter is prohibited from commenting any work with(n highway ROW error to issuance of a tulty endorsed and validated permit. <br />Permit, plan exhibit, insurance cenificate(s)•, and traffic control plan', must be available on site during work ('See Std. Provisions) <br /> <br />Your request ro use end/w occupy state highway system tight of way as tlescdbetl above Is prentetl subject to the terms antl condltlons of this permit Induding the StarMard and <br />Special Provlslons, as shown on the FRONT antl BACK hereof. IT IS UNDERSTOOD tlraz Ne Perminee vAA atnompASh iha work a[ rro expense ro the Departrnent antl wiA own antl <br />malnteln the fadlltles permittetl. <br />Permittee hereby easumea, releases antl agrees ro Intlemniry, delenQ proted aM save the Slate or Colorado harmless from antl agalnat any loss of arM/or damage to are property <br />al the State or Coorado, third partles or are Permittee's fadlltlea, antl ell loss endla damage on account of Injury w w tleath of any parsons whomsoever, arising at any tlme, caused <br />by or growing out of the ocatpetlon of Colorado State Highway rights of way by Permittae's fadlltles or any pen Mereot Including but not Ilmlted [o Installatlon, atlJustrnent reiomtlon, <br />malntenanca or operatlon, or removal of existlng taGlitles, unless such loss enNa tlamage arises hom the sole negligence or wIINI wndud of the State of Cdoratlo or Its employees <br />or agents. <br />Failure by the Permittee to rompiy witlt any of the Irldutletl terms a corrWtlorrs play sllb)ed tlrls permit ro suapenaicn or car7cetlatlon, at the WSaetlon of the Department of <br />Transportatlon. <br />THIS PERMIT IS NOT VADD UNTIL FULLY ENDORSED BY ALL PARTIES, WITH DATE OF ISSUE AFFIXED BY AN AUTHORIZED REPRESENTATIVE OF THE DEPARTMENT. <br />A FULLY EXECUTED COPY OF THIS PERMIT MUST BE ON FILE AT THE TRANSPORTATION DISTRICT OFFlCE. <br />In accepting Ws permit the undersigned, representlrrg iha Permittee, vedfles that he or she has the auaroriry to sign for and bind the Permittee, antl that he or she has read, <br />understands and accepts all the Induded oorMitlons. <br />Attested Date Signature Date <br />/ <br />ntle nor /`,~,' <br />COLORADO DEPARTMENT OF TRANSPORTATION By ( tr' ngtneer) Date of Issue <br />Chief Engineer - ~~ (~ OZ <br />Prcwoua sditiona may be aged until suppme~ sxheueted CDdr Forth e333 9192 <br />