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19) Check with the issuing authority to determine which of the following documents are required Ie complete the review of your application. <br />a) Property map indicating other access, bordering roads and sVeets. e) Subdivision, coning, or development plan. <br />b) Highway and driveway plan profile, f) Proposed access design. <br />c) Drainage plan showing impact to the highway right-of-way. g) Parceland ownership maps including easements. <br />d) Map and letters detailing utility locations before and after h) Traffic studies. <br />developmentin antl along the dght-of-way. i) Proof of ownership. <br />1- It is the applicant's responsibility to contact appropriate agencies and obtain all environmental clearances that apply <br />to their activities. Such clearances may inGude Corps of Engineers 404 Permits or Colorado Discharge Permit System <br />permits, or ecological, archeological, historical or cultural rosouroe 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 Permit offices or accessed via the <br />CDOT Planning/Construction-Environmental-Guidance webpage htto•//www dot state co us/environmental/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 Safety 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 1926 <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 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 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/ISF~4 107-1999, 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 comply with OSHA's PPE requirements for foot protection per 29 CFR 1910.136, 1926.95, <br />and 1926.96. If required, such footwear shall meet the requirements of ANSI Z41-1999. <br />Where any of the above-referenced AN51 standards have been revised, the most recent version of the standard shall <br />apply. <br />3- The Permittee is responsible for complying with [he Revised Guidelines that have been adopted by the Access Board <br />under the American Disabilities AG (ADA). These guidelines define traversable slope requirements and prescribe the <br />use of a defined pattern of truncated domes as detectable warnings 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.co.us/DesignSuoporU>, then cliGc on Design Bulletins. <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 not consistent wRh the terms and conditions listed on the permit may be considered a violation of the <br />permit. <br />The applicant declares under penaky 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 are to the best of their knowledge <br />true and complete. <br />I understand receipt of an access permit does not constkute permission to start access construction work. <br />Applicant's signature Pdnt name Date <br />// ~ - k ~l Leo~r~ 54 S-/- o~ <br />If the applicant is not the own 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 property owner, in most <br />cases, will be listed as the pertnittee. <br />Property owner si nature Print name AN A Qr~( Date „„// <br />t <br />S'l- <br /> <br />S O <br />V <br /> OyCC !~ U.]'ZII <br />/~ <br />Previous editions are obsolete and mey not be used Page 1 of 1 COOT Form p137 11/04 <br />