HomeMy WebLinkAboutState HWY access permit applicationCOLORADO DEPARTMENT OF TRANSPORTATION Issuing authority application STATE HIGHWAY ACCESS PERMIT APPLICATION acceptance date: Instructions: • Contact the Colorado Department of Transportation
(CDOT) or your local government to detennine your issuing authority. • Contact the issuing authority to determine what plans and other documents_ are reg~j'i.ep.~.p.~ s~mjtted with your
application. Please print • Complete this form (some questions may not apply to you) and attach all n..~€~~ Qo.c .\i'&nts nd Submit it to the issuing authority. -Submit an application
for each access affected. ' or type • If you have any questions contact the issuing authority. . .,. ..,' _ .,' • For additional information see coors Access Management website at hn~:/twww.ddt.staje
:co;uSfAcc~SPermitslindgx.htm 1) Property owner (Permittee) 2) Applicant Of Agent f~r p.ern;!J...tt,M ~N.gifferent from property owner) Clough Sheep Company Noble Eneri;Pi{A H-ft.J Street
address Mailing address P.O Box 686 800 Airport Road City, state & zip I Phone # City, state & zip I Phone # (required) Rifle Colorado 81650 970-625-9024 Rifle Colorado 81650 970-625-1494
E·mail address E-mail address if available cloughlivestock@hotmail.com jkirkpatrick@nobleenergyinc.com 3) Address of property to be served by permit (required) Hwy 6 and 24 4) Legal
description of property: If within jurisdictional limits of Municipality, city andlor County, which one? county [ subdivision [ block [lot [ section [townshiP I range Garfield Sec 22
T6S R94W 5) What State Highway are you requesting access from? 6) What side of the [i]way? Hwy 6 & 24 ON .s DE Ow 7) How many feet is the proposed access from 'he nearest mile post?
I How many feet is the proposed access Irom the nearest cross street? 100 feetoNDsDEiiilW)from: MM 85 1500 leetON Os DE i1W1from: 212348 Hwy 6 8) What is the approximate date you intend
to begin construction? 7/5/2012 9) Check here if you are requesting a: Dnewaccess Dtemporary access (duration anticipated; ) Dimprovement to existing access IiIchange in access use Dremoval
of access Delocation of an existing access (provide detail) 10) Provide existing property use Oil and gas facilities, agricultural 11) Do you have knowledge of any State Highway access
permits serving this property, or adjacent properties in which you have a property interest? E1no Dyes, if yes· what are the permit number(s) and provide copies: andlor, permit date:
12) Does the property owner own or have any interests in any adjacent property? Dno E]yes, if yes· please describe: SW/4, SE:1/4,NE1/4, Sec 22: T 6 S, R 94 W 6th P.M. 13) Are there other
existing or dedicated public streets, roads, highways or access easements bordering or within the property? Elno o yes, if yes· list them on your plans and indicate the proposed and
existing access points. 14) If you are requesting agricultural field access· how many acres will the access serve? 15) If you are requesting commercial or industrial access please indicate
the types and number of businesses and provide the floor area square footage of each. businessfland use square footage business square footage WPX Energy 1130680 Oil and gas production
(2) 1261360 Noble Energy 1 2500 SCADA tower I 2500 16) If you are requesting residential deveJopementaccess, what is the type (single family, apartment, townhouse) and number of units?
type number of units type number of units I 1 1 I 17) Provide the following vehicle count estimates for vehicles that will use the access. Leaving the property then returning is two
counts. Indicate if your counts are # of passenger cars a~d light trucks at peak hour volumes /I 01 multi unit to'\Jcks al peak hour volumes Dpeak hour volumes or E]average daily volumes.
4 , 01 single u~iI vehicles in excess 01 30 It # of farm vehicles {fiekl equipment} Total count of all vehicles 4 Previous editions are obsolete and may not be used Page 1 of 2 COOT
Form #137 01{10
18) Check with the issuing authority to determine which of the following documents are required to complete the review of your application. a) Property map indicating other access, bordering
roads and streets. e) Subdivision, zoning, or development plan. b) Highway and driveway plan profile. ~ Proposed access design. c) Drainage plan showing impact to the highway right·of-way.
g) Parcel and ownership maps including easements. d) Map and letters detailing utility locations before and after h) Traffic studies. development in and along the right-of-way. i) Proof
of ownership. 1-11 is 1he 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 COOT Environmental Clearances
Information Summary presents contact information for agencies administering certain clearances, information about prohibited discharges, and may be obtained from Regional COOT Utility/Special
Use Permit offices or accessed via the COOT Planning/Construction-Environmental-Guidance webpage hllp:llwww.dot.state.co.us/environmentaI/Forms.asp. 2-All workers within the State Highway
right of way shall comply with their employer's safety and health policiesl procedures, and all applicable U.S. Occupational Safety and Health Administration (OSHA) regulations· including,
but not limited to the applicable sections of 29 CFR Part 1910· Occupational Safety and Health Standards and 29 CFR Part 1926 -Safety and Health Regulations for Construction. Personal
protective equipment (e.g. head protection, footwear, high visibility apparel, safety glasses, hearing protection, respirators, gloves, etc.) shall be worn as appropriate for the work
being performed, and as specified in regulation. At a minimum, all workers in the State Highway right of way, except when in their vehicles, shall wear the following personal protective
equipment: High visibility apparel as specified in the Traffic Control provisions of the documentation accompanying the Notice to Proceed related to this permit (at a minimum, ANSI/ISEA
107-1999, class 2); head protection that complies with the ANSI Z89.1-1997 standard; and at all construction sites or whenever there is danger of injury to feet, workers shall comply
with OSHA's PPE requirements for foot protection per 29 CFR 1910.136, 1926.95, and 1926.96. If required, such footwear shall meet the requirements of ANSI Z41-1999. Where any of the
above·referenced ANSI standards have been revised, the most recent version of the standard shall apply. 3· The Permittee is responsible for complying with the Revised Guidelines that
have been adopted by the Access Board under the American Disabilities Act (ADA). These guidelines define traversable slope requirements and prescribe the use of a defined pattern of
truncated domes as detectable warnings at street crossings. The new Standards Plans and can be found on the Design and Construction Project Support web page at: shllp:/lWWw.dot.state.co.us/DesignSupp
orV>, then click on Design Bulletins. 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 access not consistent
with the terms and conditions listed on the permit may be considered a violation of the permit. The applicant dec/ares under penalty of perjury in the second degree, and any other applicable
slate or federal laws, that all information provided on this form and submitted attachments are to Ihe besl of their knowledge Irue and complele. I understand receipt of an access permit
does nol constitule permission to slarl access conslruction work. APp~~~ent fOd~ure Print name Dale ~~.\ ~ James F. Kirkpatrick June 4, 2012 /' .a, \J ~ ~; applicant is not tr~~ner of
the property, we require Ihis application also to be signed by Ihe property owner or their legally authorized presentative (or olher acceptable writlen evidence). This signature shall
constilute agreemenl with Ihis application by all owners-of-interest unless stated in writing. If a permit is issued, the property owner, in most cases, will be listed as Ihe permittee.
Property owner signature ~, ~. Print name O:hl) ~ /~ '" David Ryan McKensie <----------J //Previous editions are obsolete and may not be used Page 2 of 2 CDOT Form #137 01/10