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COLORADO DEPARTMENT OF TRANSPORTATION <br />STATE HIGHWAY ACCESS PERMIT APPLICATION <br />Issuing authority application <br />acceptance date: <br />Instructions: -contact the Department of Transportation or your local government to determine your issuing authority. <br />- contact the issuing authority to determine what plans and other documents are required to be submitted <br />with your application. <br />- complete this form (some questions may not apply to you) and attach all necessary documents and <br />submit it to the issuing authority. Submit an application for each access requested. <br />- if you have any questions contact the issuing authority. Please print or type <br />1)Pro erty owner (Peanitlee) <br />~o <br />l <br />~ <br />`~ <br />2 <br />t <br />l <br />t <br />~ ~O <br />Cf~' <br />C <br />'~ 2)Applicant <br />~ <br />~ <br />- <br />, 1 <br />. <br />~c <br />1 <br />.\ <br />)n <br />-- <br />~ <br />~ <br />uC <br />I AME 95 <br />E MYiTfiE <br />street address, city street address, city <br />~ (~ ~X r ~2 I ~ 4n lr.. <br />stale & zip p yone N stale & zip phone ft <br />e610rcu~ 8 (~ta~ ~1~o-3zs-y~g <br />3) Address of propety lobe served by permit (il known) <br />1'Tq liw S O <br />4) legal descdplion of propeny: <br />caenly subdivision Mock lot section lmvnship range <br />o uwinY SWI/y NWl4 ~9 `I4N 7~q( <br />5) What stale highway are you requesting access from? 6) Whal side of the highway ^ N ^ S ~I E ^ W <br />550 <br />~) How many feel is the proposed access from the nearest mile post? How many feel is the proposed access from the nearest cross street? <br />I $50 feet (circle: N E W )from: 9 S ~I$50 feel (circle: S E W )from: `ice RY>= <br />6) Check here if you are requesting a <br />~ new access ^ temporary access ^ improvement to existing access ^ change in access use ^ removal of access <br />9) What is the approxilnale dale you intend to begin cdnslrucllon? <br />1 O~ <br />10) Do ve knowledge of any Stale Highway access permits serving this property, or adjacent properties in which you have a properly Interest. <br />o ~$( yes, if yes -what are the permit number(s)?: S ~,~ p~ ~ and/or, permit date: S~~"7`~j'u-~ <br />11) Does the properly owner own or have any interests in any adjacent properly? <br />~ no ^ yes, if yes -please describe: <br />12) Are (here olherexisling or dedicated public slreels, roads, highways oraccess easements bordering or within the propeny? <br />~ no ^ yes, if yes -list them on your plans and indicate the proposed and existing access points. <br />13) If you are requesting commercial orindustrial access please indicate the types and number of businesses and provide the floor area square footage of each. <br />business square loolage business square footage <br />S"~OR E Fgclr_ISy a40a <br /> <br />14) If you are requesting agricultural field access -how many acres will the access serve? <br />15) If you are requesting resideNial developement access, what is the type (single family, apartment, townhouse) and number of units? ~. <br />lope number of units type number of units ~' <br />16) Provide the following vehicle count estimates for vehicles (hat will use the access, Leaving the propedy then returning is two counts. Indicate if your counts are <br />^ peak hour volumes or ~' average daily volumes. <br />N of passenger cars aM light (rucks / of multi unit (rucks • of Omer venmles <br />ID <br />p of single unit vehicles in excess 013011. N of farm vehicles (field equipment) Total count of all vehicles <br />Check with the Issuing authority to determine which of the following documents are requiretl to <br />(plans should be no largerthan 24" x 36") <br />a) Highway and driveway plan profile. <br />b) Drainage plan showing impact to the highway right-of-way. <br />c) Map and letters detailing utility locations before and after <br />development in and along the right-of-way. <br />d) Subdivision, zoning, oroevelopmenl plan. <br />ro <br />review of your application. <br />Property map Indicating other access, bordering roads and slreels. <br />Proposed access design <br />Parcel and ownership maps including easements. <br />Signing and striping plans. <br />Traffic control plan. <br />Proof of liability insurance. _ <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 permitted <br />access not consistent with the terms and conditions listed on the permit may be considered a violation of the permit. <br />The app{icant dec{ares under penalty of perjury in the second degree, and any other applicable state or federal <br />laws, that all information provided on ttlis form and submitted attachments are to the best of their knowledge true <br />and complete. <br />plica~ptls signature <br /> <br />If the applicant i ns of file owner of the property, we require this application also to be signed by the property owner or their <br />legally authorized representative (or other acceptable written evidence). This signature shall constitute agreement with this <br />application by all owners-oi-interest unless staled in writing. If a permit is authorized, the property owner wiN be fisted as <br />the permittee. <br />owner <br />Dale <br />Previous etlilions may be usetl until supplies are exhaustetl <br />