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Application requirements - submit with completed application form <br />in sets of four - <br />1. LETTER OF REQUEST (on letterhead of City or Utility Company) as necessary to: <br />a. document that the owner concurs in the application, if the applicant is other than the permittee; and /or <br />b. more fully describe the nature of the proposed work, status of required clearances (see item 5 below), etc. <br />2. PLAN AND PROFILE clearly showing the following: <br />a. Distance of the proposed work or facility from right-of-way (ROW) line. <br />b. Distance from S.H. milepost and intersection streets. <br />c. *Distance line will be within ROW, or if it crosses ROW. <br />d. *Facility type: (Water, Gas, Phone, Power, Fiber Optic cable, Oil, etc.). <br />e. *Nature of installation: (buried, overhead, or attached to a highway structure). <br />If attached to a highway structure, submit a separate drawing, indicating the structure number, <br />And showing attachment details. <br />*If application is for Utility Permit <br />3. TRAFFIC CONTROL PLAN (required on all operations) that conforms to the "Manual on Traffic Control <br />Devices for Streets and Highways" (Part VI). <br />4. INSURANCE REQUIREMENTS: <br />a. A permittee shall ensure that all permitted operations, whether performed by the permittee or by <br />subcontractors, are adequately and continuously covered by liability insurance. The types and minimum <br />amounts of insurance acceptable to CDOT are as follows: <br />1. Workers Compensation Insurance in accordance with prevailing laws. <br />2. Comprehensive General Public Liability and Property Damage Insurance: <br />Combined Bodily Injury and Property Damage <br />$150,000 per person <br />$600,000 each occurrence <br />3. Comprehensive Auto Liability and Property Damage Insurance: <br />Combined Bodily Injury and Property Damage <br />$150,000 per person <br />$600,000 each occurrence <br />b. Certificate(s) of Insurance from permittee and/or subcontractors' insurance carrier(s), naming Colorado <br />Department of Transportation as additional insured party, shall be furnished. <br />5. ENVIRONMENTAL CLEARANCES: <br />It is the applicant's responsibility to contact appropriate agencies and obtain all environmental clearances that apply to <br />their activities. Such clearances may include Corps of Engineers 404 Permits or Colorado Discharge Permit System <br />permits, or ecological, archeological, historical or cultural resource 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 littp://www,dot.state.co.t)s/eiivironniciiiiii/ForniLM. The <br />letter of request for a Utility or Special Use Permit must include a discussion of the status (e.g. application submitted, <br />permit received, etc.) of any clearances that apply to the applicant's activities. Utility or Special Use Permits conditionally <br />require compliance with all applicable regulations - including environmental regulations, and all clearances identified in <br />the applicant's letter of request must be obtained prior to commencing work. <br />Page 2 COOT Form #1233 01104