Laserfiche WebLink
• <br />L~ <br />r B) Chock wlrh the roauuq authodry m determine which ofthe bpowmg dxumenla are required A wmpbra the revlewotyour appllprion. <br />a)Propedy mapiMicabna Othv ecceu, boroennp roads and chaom. e) 5uhdiviaion, mrdng, or devUoprtrentp4n. <br />b) Fiiarwayanddnveway Oran profile. p Proposed BCrBaedeilgn. <br />c) Drotnage Plan anowirrp impeclmtne Aighwayrlglrt-0MVay. q) Parcel and ewnerahiD maps including eacerrorlo. <br />d) Mep arq briars demikng upllry lauriona Defers and efrer h) Trams aardiee. <br />devempmeMin and along pre rigMa/-way. q Proof o(ownarshp. <br />t- It is the appticanYs responsibility to contact appropriate agencies and obtain all environmental clearances that apply <br />to their activities. Such clearances may include Corps at Engineers 404 Permits or Colorado Discharge Permit System <br />permits, or ecological, ercheolopical, historical or cuHural resource clearances. The CDOT Envhnmentel Gearances <br />Information Summary presents contact information for agencies administering certain clearances, information about <br />prohibited discharges, and may be obtained /rom Regional Ci7O7 UtilitylSpecial Ilse Permit offices fir accessed via the <br />CDOT Planning/Construction-Environmental-Guidance webpage A~tDflyww.doLState.co.us/envi.anmentalfForms.asg. <br />2- All workers within the State Highway right of way shall comply with !heir empbyeYS aa/ety and health poliuesl <br />procedures, and all applicable U. S. occupational Safety end Realth Administration (OSHA) regulations -including, but not <br />limited to the epplieaWe sections o} 29 CFR Part 1910 • Occupational Safety and Health Standards and 29 CFR Part 1926 <br />• Safety and Health Regulations for Gonstruclion. <br />Personal protective equipment (c.g. head protection, footwear, high visibility apparel, safety glasses, hearing protection, <br />respirators, gloves, etc.) shall tre worn as appropriate for 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 (dlovdng personal <br />protective equipment: High visibility apparel as specified in the Traffic Crintrol provisions of the documenlalion <br />accompanying the Notice to Proceed related to this permit (at a minimum, ANSI/ISF~4 107.1999, class 2); head <br />protection that complies with the ANSf 289.1-1997 standard; and at all conslrucdon sites or whenever there is danger of <br />injury to feet, Workers shall comply wkh OSHA's PPE requirements for foot prolecdon per 29 CFR 1910.136, 1926.95, <br />and 1928.96. If required, such footwear shat! meet the requirements of AN51 Z41-1999. <br />Wtrere any of the above-referenced ANSI standards have been revised, the most recent version of the standard shall <br />apply. <br />3- The Permittee is responsible for complying with the Revised Guidelines that have been adopted by the Access Board <br />under the American Disabllltles Act (ADA). These guldeUnes define treversable slope requirements and prescribe the <br />use of a defined pattern of truncated domes as detectable wemings at sVee! crossings. The new Standards Plrtns and <br />can be found on Me Design and Constuction Project Support web page et <br />~R•//www dot.state co uslDesignSuoooR/>, then click on Design BulleSns. <br />If an access permit is issued to you, it will slate the terms and conditions for its use. Any chances In the use of the <br />permitted access not consistent with the terms end condibons listed on the permit may be considered a violation of the <br />permit. <br />The applicant declar®6 under penalty of perjury in the second degree, and any otherapplicable state orfederal <br />laws, that all information provided on this form and sUMnitted atfachmenta are to the best of their knowledge <br />true and complete. <br />I understand receipt of an access permit does not constitute pertnisaion to start access concwction vrork. <br />Appl¢mt'selgnarure Pnmrume mm <br />r <br />W~.._, n,..~ J ~ ~~, r..v.5 L <br />~ Z`I 0 (a <br />If the applicant is not the owner of the pproperty, we require this application also W be signed by the property owner or <br />their legally authorized re resentative (or other acceptable written evidence), This signature shall wnsbtute agreement <br />with this application by alt owners-oFinterest unless stated In writing. If a permit is issued, the property owner, In most <br />cases, will be listed as the permiltee. <br /> <br />Pmpem owner argruorro Printrerre am <br /> <br />S,Fvt/rt7u,e z. <br />Prerraa adltlvne n ewalab ana nrry n W be uead <br />7 <br />Paaakor2 COOT FOrm TaT 7101 <br />ATT/7./FFT/ GC:7T 9001/6i/b0 <br />