2010-07-27_REVISION - M1977223 (13)

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Application requirements - submit with completed application form Submit required application documentation in sets of four - collated 1. LETTER OF REQUEST (on letterhead of City or Utility Company) as necessary to: a. document that the owner concurs in the application, if the applicant is other than the permittee; and/or b. more fully describe the nature of the proposed work, status of required clearances (see item 5 below), etc. 2. PLAN AND PROFILE clearly showing the following: a. Distance of the proposed work or facility from right -of -way (ROW) line, b. Distance from S.H. mile post and intersecting streets, c. *Distance line will be within ROW, or if it crosses ROW, d. *Facility type: (Water, Gas, Phone, Power, Fiber optic cable, Oil, etc.), e. *Nature of installation (buried, overhead, or attached to a highway structure). If attached to a highway structure, submit a separate drawing, indicating the structure number, and showing attachment details. *If application for Utility permit only 3. TRAFFIC CONTROL PLAN (required on all operations) that conforms to the "Manual of Uniform Traffic Control Devices for Streets and Highways" (Part VI). 4. INSURANCE REQUIREMENTS: The Permittee shall obtain and maintain insurance at all times during the performance of work authorized by this Permit, in the kinds and amounts specified in the attached document "Insurance Requirements for CDOT Utility and Special Use Permits ". The Permittee shall require any Contractor working for them within the State Highway Right of Way to obtain like coverage. Certificates of insurance shall name the Colorado Department of Transportation as additional insured party. 5. ENVIRONMENTAL CLEARANCES: 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 Utility /Special Use Permit offices or accessed via the CDOT Planning/ Construction - Environmental- Guidance webpage http: /www.dot.state.co.us /environmental /Forms.asp. The letter of request for a Utility or Special Use Permit must include a discussion of the status (e.g. application submit- ted, permit received, etc) of any clearances that apply to the applicants activities. Utility or Special Use Permits condi- tionally require compliance with all applicable regulations - including environmental regulations, and all clearances identified in the applicant's letter of request must be obtained prior to commencing work. Return completed application plus all required enclosures to Colorado Department of Transportation, Attn: Utility Permit Office, at one of the following addresses as appropriate to this permit: Region 1: 18500 East Colfax Avenue Region 2: 905 Erie Avenue Aurora, CO 80011 Pueblo, CO 81001 303 -365 -7306 719- 546 -5403 Region 3: 222 South 6th Street, Room 100 Region 4: 1420 2nd Street Grand Junction, CO 81501 -2769 Greeley, CO 80632 970 - 683 -6271 970 - 350 -2111 Region 5: 3803 N Main Avenue, Suite 300 Region 6: 2000 South Holly Street Durango, CO 81301 Denver, CO 80222 970 - 385 -8360 303 - 512 -4272 Previous editions of this form are obsolete and may not be used Page 2 of 4 CDOT Form $1233 10107