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td) Check with the issuing authority to determine which of the blowing documents are required to complete the review of your application. a) Property map indicating other access, bordering roatls and streets. e) Subdivision, zoning, or development plan. b) Highway and driveway plan profile. t) Proposed access design. c) Drainage plan showing impact to the highway right-of-way. g) Parcel and ownership maps including easements. d) Map and letters detailing utility locations before and after h) Traffic studies. _ development in and along lheright-of-way. iJ Proof of ownership. 1- It is the applicant's responsibility to contact appropriate agencies and obtain all environmental clearances that apply to their activities. Such clearances may include Corps of Engineers 404 Permits or Colorado Discharge Permit System permits, or ecological, archeological, historical or cultural resource clearances. The CDOT Environmental Clearances Information Summary presents contact information for agencies administering certain clearances, information about prohibited discharges, and may be obtained from Regional CDOT UtilitylSpecial Use Permit offices or accessed via the CDOT Planning/Construction-Environmental-Guidance webpage h„~~llwww dot state co us/environmental/Forms asp. 2- All workers within the State Highway right of way shall comply with their employer's safety and health policies/ procedures, and all applicable U.S. Occupational Safety and Health Administration (OSHA) regulations -including, but not limited to the applicable sections of 29 CFR Part 1910 -Occupational Safety and Health Standards and 29 CFR Part 1926 - Saferiy and Health Regulations for Construction. Personal protective equipment {e.g. head protection, footwear, high visibility apparel, safety glasses, hearing protection, respirators, gloves, etc.) shall be worn as appropriate for the work being pertormed, and as specified in regulation. At a minimum, all workers in the State Highway right of way, except when in their vehicles, shall wear the following personal protective equipment: High visibility apparel as specified in the Traffic Control provisions of the documentation accompanying the Notice to Proceed related to this permit (at a minimum, ANSI/ISEA 107-1999, class 2); head protection that complies with the ANSI 289.1-1997 standard; and at all construction sites or whenever there is danger of injury to feet, workers shall comply with OSHA's PPE requirements for foot protection per 29 CFR 1910.136, 1926.95, and 1926.96. If required, such footwear shall meet the requirements of ANSI Z41-1999. Where any of the above-referenced ANSI standards have been revised, the mast recent version of the standard shall apply. 3- The Permittee is responsible for complying with the Revised Guidelines that have been adopted by the Access Board under the American Disabilities Act (ADA). These guidelines define traversable slope requirements and prescribe the use of a defined pattern of truncated domes as detectable warnings at street crossings. The new Standards Plans and can be found on the Design and Construction Project Support web page at: <http://www.dot.state.co.uslDesignSuaaort/> then click on Design Bulletins. !f an access permit is issued to you, it will state the terms and conditions for its use. Any changes in the use of the permitted access not consistent with the terms and conditions listed on the permit may be considered a violation of the permit. The applicant declares under penalty of perjury in the second degree, and any other applicable state or federal laws, that all information provided an this form and submitted attachments are to the best of their knowledge true and complete. I understand receipt of an access permit does not constitute permission to start access construction work. iApplicant's signature Print name Date ~~~ CCf~ ~ ~ ~ - ~~,wX~~ J ,~uc`~ T_ /Lli, sJ r ~ LLB ~ rZZ I b I` If the applicant is not the owner oi.the property, we require This application also to be signed by the property owner or their Ieg~ awthorized representative (or other acceptable written evidence). This signature shall constitute agreement with [his ap atidn by~all owners-of-interest unless stated in writing. If a permit is issued, the property owner, in most cases; will be Yed as tide oermiktee. I Date j I ~I -~ i'I i-j ~_% Previous editions are obsolete antl may not be used Page 2 of 2 CBOT Farm #117 121