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COLORADO DEPARTMENT OF TRANSPORTATION Please print or type <br />UTILITY/SPECIAL USE PERMIT APPLICATION <br />Instructions: <br />Complete this form, attach all required documents, and submit it to the appropriate permit office. To determine which documents are required, <br />refer to page 2 of this form and /or contact the Permit Office. You must submit all required documents orthe application will be <br />deemed to be incomplete and will not be accepted. Please do not FAX completed forms or documents. <br />Permittee: property or utility owner <br />Name <br />Address <br />Contact person e-mail address <br />Telephone <br />Applicant if other than permittee <br />Name <br />Address <br />Contact person e-mail address <br />Telephone <br />Arttivifv rlpsrrintinn• lftirnichPri by nerrnitteel <br />Purpose of Utility Permit <br />❑Installation ❑ Adjust/relocation ❑ Removal ❑ Maintenance of existing facility <br />Facility (type, size, class of transmittant, design pressure or potential, etc. <br />Nature of installation ❑ Longitudinal (parallel) ❑ Buried* ❑ Aerial /Ground- mounted <br />Transverse (crossing) ❑ Attach to Highway Structure #: <br />Purpose if for other than Utility Permit <br />❑Landscaping ❑ Survey ❑ Spill cleanup ❑ Site restoration <br />❑ Construction within right -of -way [] Other (describe): <br />State Highway No. <br />County <br />City/Town <br />Location relative to SH milepost(s) <br />Location relative to intersecting feature(s), e.g., cross street, str. #, etc. <br />Intended start date and planned duration of work <br />Additional remarks <br />If Permittee will own or operate underground facilities in State Highway rights -of -way: Indicate contact person for <br />underground location information: <br />Telephone <br />"Notice to Excavators: Pursuant to 9 -1.5 -103 C.R.S., excavators shall not make or begin any excavation wltnout Tfrst notlty- <br />ing the Utility Notification Center of Colorado (UNCC) and if necessary, then notifying the tier two members having under- <br />ground facilities in the area of such excavation. Notification shall also be given to the CDOT regional permitting office, or as <br />otherwise directed by the Special Provisions of the permit that is issued. Notice of the commencement, extent and duration <br />of the excavation work shall be given at least two business days prior thereto, not including the day of actual notice. The <br />UNCC may be called at 1- 840 - 922 -1987. <br />See reverse side for additional instructions Previous editions of this form are obsolete and may not used <br />Page 1 of 4 CDOT Form 91233 3 110107 <br />