HomeMy WebLinkAboutWell InformationDocu5ign Envelope lD: DEB35D79-0E6D-4555-BD2E-CF5058685526
COLORADO
Department of Transportation
Region 3
R3 Traffic Section, Access Unit
222S6th St, Rm 100
Grand Junction, CO 81501
PH (970) 683-6284 FAX (970) 683-6290
<<<<< e-mai[ed >>>>>
August 8, 2023 Permit No. 323122
Tom & Naomi Laidtaw
234 County Road 236
Sitt, Cotorado 81652
Dear Permittee:
1. Please review theattached State HighwayAccess Permit (Form #101)and attenctosed attachments
2. lf you ACCEPT the Permit and its Terms and Conditions (and are authorized to sign as legat owner of
the property, or as an authorized representative), ptease comptete the Docu5ign process within 60
days of the transmittal date on the permit. Your signature confirms your agreement to att the listed
Terms and Conditions.
3. lf you fail to comptete the DocuSign within 50 days, the Cotorado Department of Transportation
(CDOT) wi[[ consider this permit withdrawn.
4. You may use the PayPal tink to pay for this permit <ir send a check or money order made payabte to
"CDOT" for the total amount due of 550.00 to our office.
5. lf you wish to APPEAL the Terms and Conditions of the permit, ptease refer to the attached Form
101, Pages 2 and 3 for an exptanation of the appeal procedures.
6. As described in the additional attached Terms and Conditions, you must make a written request to
obtain a Notice to Proceed. DO NOT begin any work within the State Highway Right-of-Way without
a vatidated Access Permit and Notice to Proceed. Use of this permit without the Cotorado Department
of Transportation's vatidation shatl be considered a viotation of State Law.
lf you have any questions ptease catl Kandis Aggen, Asst. Access Manager, at (970) 683-6270 or Brian
Kittian, Region 3 Access Program Manager, at (970) 683-6284.
lf you choose to return the signed permit and/or check by mait, please send to:
Region 3 Access Unit
Attn: Kandis Aggen, Asst. Access Manager
2225 6th St, Rm 100
Grand Junction, CO 81501
rest
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R3TrafficSection, AccessUnit, 22?S.6th Street, Rm 100, GrandJunction, CO 81 50'l PH (970) 683-6284 www.codot.gov
DocuSign Envelope lD: DEB36D70-0E6D4SSS-BD2E-CFS0SB6BOS26
COLORADO DEPARTMENT OF TMNSPORT
STATE HIGHWAY ACCESS PERMIT
CDOT Permit No.
323122
State Highway No / Mp / Side
07041 101.503 / Right
Permlt Fee
$50.00
Date of Transmittal
08108t2023
Region / Section / Patrol / Name
3 I 02 I 2K10 Tracy Anthony
Local Jurisdiction
Garfield County
is hereby granted permission to have an access to the state highway at the location noted below. The access shall be constructed, maintained and used in
accordance with this permit, includlng the State Highway Access Code and any attachments, terms, conditions and exhibits. This permit may be revoked
by the lssuing Authority if at any time tho permitted access and its use violate any parts of thls permit. The issuing authority, the Departmeniand their duly
appointed agents and employees shall be held harmless against any action for personal injury or property damage sustained by reason of the exercise of
the penxit.
The Applicant(s):The Permittee(s):
Tom & Noomi Laidlaw
234 County Road 236
Silt, Colorado 81652
(970) 618-6051
the south side of the l-70 South Frontage Rd. (aka River Frontage Rd.) approximately 2635 feet east of MP 101
-1 07.578936)
Location: Located on
(Lat. 39,553635, Long.
Access to Provide Service to: (Land usc codc)
210 - Single-Family Detached Houslng
(Size)
1
(Units)
DHV
Additional lnformation:
MUNICIPALITY OR COUNTY APPROVAL
Required only when the appropriate local authority retains issuing authority
Signature Print Name Date Title
Upon the signing of this permit the permittee agrees to the terms and conditions and referenced attachments contained
herein, All construction shall be completed in an expeditious and safe manner and shall be finished within 45 days from
lnitiation. The permitted access shall be completed in accordance with the terms and conditions of the permit prior to
being used.
The permittee shall notify Teshaylo Trujillo 2K3 with the Colorado Department of Transportation, at 970-812-7603
at least 48 hours prior to commencing construction within the State Highway right-of-way.
The person signing as the permittee must be the owner or legal representative of the property served by the permitted access and have full authority to
accept the permlt and its terms and conditions.
'PePBllfrEe€Uhature:
f-t^ * Nuui tulhw
Print Name
tom & Naomi taidlaw
Date
8/8/2023 | 4:49 PM PDr
-GoqdecmiHes6Hgnature: (if applicable)Print Name Date
This permit is not valid until signed by a duly authorized representative of the Department.
COLORADO DEPARTMENT OF TRANSPORTATION
-slum$t/rueo Dv:
*w{"q*--
Print Name
randis Aggen
Title
Asst. Access Manager
Date (of issue)
8/LL/2023 | L0:40 AM PDr
Required:
l.Region
2.Applicani
3.StaffAccess Section
4.Central Files
Make copies as necessary for:
Local Authodly lnspector
MTCE Patrol Traflic Engineer
Prevlous edltlons are obsolele and may not be usedPagelof3 GDOTFoTm#101 5/07
. PocuSlenEnvelopelD:DEB35D79-0E6D*4555'BD2E-CF5058685526
State Highway Access Permit
Form'10{, Page2
The following paragraphs are exgerpts of the State Highway
Access Code. These are provided for your convenience but
do not alleviate compliance with all sections of tlre Aocess
Gode, A copy ofthe State Highway Access Code is available
frorn your local issuing authority (lgcal govemment) or the
Colorado Department of Transportation (Department)'
When thls permit was issued, the lssuing authoritymade its
decision based in part on information submitted by the
applicant, on the acgess category whlch ls. assigned to the
highway, what altemative access to other public roads and
streets is avallable, and safety and deslgn standards.
Changes ln use or deslgn not approved by the permit or the
issuing authority may cause the revocation or quspenslon of
tie permit.
APPEALS
1. Should the permltlee or applicant object to the denial of
a permlt appllcatlon by the Department or objectto any of the
terms or condiilons of a permit placed there by the
Department, the applicant and permittee (appellant), have a
right to appeal the decision to the f-Iransportatlonl
Commission [of Colorado]. To appeal a decislon, submit a
request for admlnistratlve hearlng to the T;anspgrtatlon
Commlsslon of Colorado within 60 days of tran-smittal of
notice of denial or: transmittal of the permit for signature.
Submit the request to ihe Transportation Commission of
Colorado, 4201 East Arkansas Avenue, Denver, Colorado
80222-3400. The request shall include reaFons for the
appeal and may include changes, revlsions, or conditions
that wo.uld be aqceptable tq the permittee or applicant.
2. Any appeal by the applicant or permittee of action by a
lqsal issuing authorily shall be filed with the local authority
and be consistent with the appeal procedures of the local
authpri$.
3. ln submitting the request for administrative hearing' thg
.appellant has the option of including within the appeal a
r6{uest for a review by the Depgfiment's lnternal
admlnlstrative revigw committee pursuant to lCode]
subsection 2.10. Whensuch commiftee review ls requested'
processing of the appeal for fonnal administrative hearlng,
2.9(5) and(6), shall be suspended until the appellanl notifie-s
lhe Commission to prQceed with the administrativs hearing'
or the appellant submits a request to the Commlssion or the
administrative law judge to withdraw the appeal. The brvo
administrative processeg, the intemal administratlve review
committee, and the adminlstrativg hearing, may ngt ru.n
goncunently.
4, Regardless of any communigations, meetings'
administrative reviews or negotiations with the Department
or the intemal administrative review Committee regarding
revisions or objections to the permit or a denial, if the
permittee or applicant wishes to appeal the Department's
decision to the Commission for a hearing, the appeal must
be brought to the Commission within 60 days of transmittal
of notice of denial or transmittal of the permit.
PERMIT EXPIRATION
1" A permit shall be considered expired if thq access. is noJ
under construction within one year of the permit issue dale
or before the expiration of any authorized extension. When
the pe-rmittee is unable to commence construction within one
yearafierthe pemtit issue date, the permitteemay requesta
ons yearextension from the issuing authority. No more than
two one-year extensions may be granted under any
circumstances. lf the access ls not under construcllon within
three yeats from date of issue the per:mit will be considered
expired. Any request for an extension must be in writing and
submitted to the issuing authority befor,e.the permit. expires.
The request shpuld state the reasons)whY lhe. extensio-n is
ne-cessary, when construction is anticlpated, and lnclude a
:copy of page 1 (face of permit) of the acc.ess permit.
Extension approvals shall .be in writing. The local lssulng
puthority shall pbtain the concunenge qf the Qppartment
pforto the approval of an extension, and shall notifu the
Department of all donied extensions within ten days. Any
person wjshing to rpestablislr.'an access pe.rmit that has
expired may begin again yvith,the application procadureS'An
approyed Notice to Proceed, automatically renews the
access permit for the period of the Notice to Proceed.
.CONSTRUCTION
1, Construction may not begin until a Notice to Proceed is
approved, (Code subsection 2.41
2. The construction.of the access and its appurtenances as
required by the terms and conditions of the permit shall be
completed at the expense of the permiftee excapt as
provided in su.bsection 2.14. All materials used in the
construction of the access within the hlghway right-of-way or
on permanent easements, become pullic properly: Any
materials remgved from the highway right-of-way will be
disposed of only as directed by the Department. All fenoing,
guard rail, traffic control devices and other equiprpen-t and
materials romoved in the course of access construcUon shall
be given to the Department unless othelwise ins!ructed by
the permit or the Department inspector.
3. The permittee shall notiff the individual or the office
specified on the permit or Notice to Proceed at least two
working days prior te any construction, within state highway
righfof-way. Cons!ruction oJ the aqcess shall nol proceed
until both the acc-ess pe-rmit and the Notice to Proceed are
issued- The acoess shallbe completed in an expeditious and
safe manner and shall be linished within 45 days from
initiation of constructlon within the highway flght-of-way. A
construction time extension notto exceed 30 working days
may be requestgd from the lndividual or office specifiqd on
the pe;'mit.
4. The issulng authority and the Department may inspect
the access during construction.and upoD completion of the
access- to ensure that all tenns and .conditions of the permlt
are met. lnspectors are authorized to enforce the conditions
of the permit during construction and to halt any activltles
within state right-of:Way that do not comply wlth the
provlsions of the permlt,lhat conflicl wlth concurrent highway
construction or malnte.nance work, that endanger highway
propertyi natural or cu-ltural resources protected by law' or
the health and safety of workers or the public.
DocuSlgn Envelope lD: DEB35D7S-0EOD45SSBD2E-CFS0SB6BSSZ6
10: Each access shall be constructed in' a manner that shall
not cause watef to enter onto the roadway or shoulder, and
shell nbt interfete with'the existing drainage syst€fi on the
right-'of:way or any adopted municlpal system and drainage
plan.
5. Prior to using the access, the permittee is required to
complete the construction accordlng to the terms and
co-nditions of the permit. Fallure by the permittee to abide b'y
all permit terms and conditions shall be suffioient oausd fol
the Department or issruing authority to initiate action to
suspend or revoke the permit and close the access. lf in the
determination cif the Department or issuing authority the
fallure to r:onrply with or complete the construoflon
requirei'nents of'the pemiit create a hlghwayShfety hazard,
such shall be'suflicienl, Cuuse Tor the summary suspen$ioh
of the pormlt. lf the'permittee wlshes to uSe the access prior
to completlon, arrangements must be approved by the
lssulng authority and Department and induded in the p-ermit.
The Department or lssuing authority may order a halt to any
unauthorlzed use of the access 'pursuant to statutory and
regulatory poWers. Reconstruction or lmp-rovement of the
access may be required when the permlttee has faildd to
meet required speclficatlons of deslgn or mirterlals. lf any
cbnstruction element falls within two years due to imprcper
bonstilction cir materlal specifications, the permlttee shbll be
responsible for all repairs. Fallure to make such repalrs may
result in suspension of the permit'and closure,of the aceess.
6. The permittee shall provide construction trafflc control
devices at all tlmes during access construction, ln
conformance with the M.U.T.C.D. as required by section 42-
4-104i C|R.S., as amended.
7. A utility permlt shall be obtalned for any utility work within
highway right-of-way. Where neoessary to remove, relocate,
or repair a traffic control devlce or publlc or private uflllties for
the Constructlon of a 'permltted dccess, the relbcaticin,
removal or repair'shall bs accompllshed by the permittee
without cost to the Department or issuing authority, and 'at
the dlrectlon of the Department or rJtilltli company. Any
damage to the state hlghway or other public rightof-way
beyond that whlch is allowed in the permlt shall be'r-e;iairei
immetJiately. The piermittee is responsible fof the iepalr of
any utlllty'damaged ln the course of etccess ,cOnstru'ction,
reconstrUction or tepair.
8. ln the event it becomes necessary to remove any right-
of-way fenOe, the posts on either slde of the a'ccess shall be
secuidly braced With an approved end post befoire the fence
is cut to prevent any slackihg' of the refiaininj fence. All
posts and wire temcived are Depai.tnient property and sliall
be turned over to a'representative of the Department.
9. The permlftee shall ensure that a copy of ihe permit is
available for revlew 6t the construction Site at all times.'Ttte
permit may require the contra0tcir tb notlff the lndlvldual oi
office specifie'd dn the permit at any specified phases in
construction to allow the field inspector to Inspect various
aspects of construction such as concrets forme, cubbosc,
base course compabtion, and'materials specificaflons. M jnor
changes and additions may be ordered b'y the Departinent
or local authorlty field inspector to meei unanticipated site
cbnditions.
11. By accepling the permit, permittee agrees to ,save,
indemnify, and hold harmless to the extent allowed by law,
the issuing authority, the Department, its officers, and
employees from suits, actiohs; ctaims of any type or
character brought becaus'e of injuries ot damaEe susialned
by any person resultlng from the permitlee's use of 'lhe
access permit during the conStruction of llie access.
CHANGES IN ACCESS USE AND PERMIT VIOLATION.S
1. lt is the responsibillty 'of the property .Owner and
permittee to endure that the Use of the accoss to the property
is not in violatioh of the Code, permit terms and conditions or
the Act. The. terms and conditions of ,any permit,are binding
upon all asSigns, successors-in-interest, heirs and
occupants. lf any significant changes are made or will be
made in the use of the property which will affect access
operation, traffic volume and or vehicle type, the permittee or
properly owrershall contactthe local issuing authorig orthe
Department to determine if a new access permit and
mridifications to the access are requlrod.
2. Wheh an aocess is constructed or used ln violation of
the Code, sectlon 43-2-147(5Xc), C.R.S., of the Act applies.
The Department or issuihg Authority may Summarily suspend
an ac0ess permlt and imrmediately order closure of the
access when its continued use presentS an immediate,threat
to public health, welfare or safety. Summary suspenslon
shdll Comply with article 4 of title 24, C.R.S.
MAINTENANCE
1, The petmittee, his or her h€irs, successors-in-inter€sti
assigns, and occupants of the property serviced by the
access 'shall be responsibib for mE€iing the terms' and
conditions of the permit, the iepair and maintenance of the
access beyond the edge of lhe rdadway including any cattle
guard and gate, and the removal or clearance of snoW or ice
upon the access even though deposited on the access in the
course of Department snow reinoval operatlons. Within
unincorporated areas the. Deparlmerit will keep acceSs
culverts clean as part of niaintehance of the hlghway
.drainage system. However, the permittee iS responsible for
the repalr and replacement of any access-related oulverts
within the right-of-way. Within incorporated areas, drainage
responsibilities for municipallties arO determined'by statute
and local ordinanOe. The, Departnient will rnaintain the
roadway including'auxiliary lanes and shOulders, exc'ept in
those bases where the access installalion'has failed dde to
impropor access construction and/or failure to foilow permit
iequirementS and specifications in which case the permittee
shall be responslble for such repair. Any signifieant repaiiS
such as culvert replacement, resurfacing, or changes in
design or specifications', requireg authorization from the
Department.
Form 101, Page 3
_ DocuSlgn Envelope lD: DEB35D79-0E0D455$BD2E-GF5058685526
STATE of CoLoRADo HIGHWAY ACCESS PERMIT
ADDITIONAL TERMS and CONDITIONS
August g, ?023 PERMIT Ng.'323't22
Permittee(s): Tom & Naomi Laidlaw
Location: Garfietd County on CO Highway 070A, near Mite Ref. Pt. 101.503 Righ!
1. This permitied access is on[y for the use and purpose stated in the Application and Permit. This
Permit is issued in accordance with the State Highway Access Code (2 CCR 601-1), hereafter
referred to as the "Access Code", and is based in part upon the information submitted by the
Permittee. Any subsequent retocation, reconstruction, modifications, the type of traffic using the
access or 20% increase in votume to the access shatl require a new apptication and coordination
with Cotorado Department of Transportation, hereafter referred to as "CDOT". Any changes causing
non-comptiance with the Access Code may render this permit void, requiring a new permit.
7. This permit replaces any and alt additional access permits that may be in existence f,or this access.
3. This permit is for an as-constructed access with a change in use to single-famity residential.,
4. The total traffic volume shatt be 1 DHV (Design Hourty Volume).
5. This access sha[[ have a futt-turning movement.
6. The Permittee is responsible for obtaining any necessary additional Federat, State and/or
City/County permits or clearance. Approvat of this access permit does not constitute verification
of this action by the Permittee. Permittee is atso responsibte for obtaining atl necessary utitity
permits in addition to this access permit.
7. No drainage from this site shatl enter onto the State Highway travel lanes. The Permittee is
required to maintain atl drainage in excess of historical ftows and time of concentration on site.
Alt existing drainage structures shatl be extended, modified or upgraded, as appticable, to
accommodate atl new construction and safety standards, in accordance with the Department's
standard specifications.
8. Nothing in this permit shatl prohibit the Chief Engineer from exercising the right granted in CRS 43-
3-1O2-including, but not limited to, restricting left hand turns by construction of physicat medial
separations.
9. tt shatt be the responsibility of the Permittee to maintain adequate sight distance for this driveway.
It is the sote responsibitity of the Permittee to trim and/or remove vegetation (i.e.: weeds, grass,
shrubs and trees) to maintain adequate sight distance.
10. The permittee, his or her heirs, successors-in-interest, assigns, and occupants of the property
seruiced by the access shatl be responsible for meeting the terms and conditions of this permit, the
repair and maintenance of the access beyond the edge of the roadway including any cattle guard
and gate, and the removal or clearance of snow or ice upon the access even though deposited on
the access in the course of Department snow removat operations. Within unincorporated areas, the
Department witl keep access culverts ctean as part of maintenance of the highway drainage system.
However, the permittee is responsibte for the repair and reptacement of any access-retated
cutvefts within the right-of-way. Within incorporated areas, drainage responsibitities for
municipatities are determined by statute and local ordinance. The Department witl maintain the
roadway inctuding auxiliary lanes and shoulders, except in those cases where the access instatlation
has faited due to improper access construction and/or failure to follow permit requirements and
specifications in which case the permittee shatl be responsibte for such repair. Any significant
repair such as cutvert reptacement, resurfacing, or changes in design or specifications, requires
authorization from the Department.
DocuSlgn Envolope lD! DEB36D79-0E6D4SS5-BD2E-CFS0SB685SZ6
STATE of COLdRADO HIGHWAY ACCESS p,ERMtT
ADDITIONAL TERMS and coNDlTloNS
August 8,2023 pER\^lT No. 3*122
Permittee(s): Tom & Naomi LaidlawLocation: Garfietd county on co Highway 070A, near Mile Ref. pt. 101.503 Right
11. Att coqts associated with any type of utitity work witl, be at the sote responsibitlty and cost of the
Permittee and at no cost to CDOT.
'1'2. Any current or'proposed cattte guard shatl. be maintaihed futLy within the property boundaries and
atl repaiis aie.the s0[e responsibitity of the property owner.
13. Backing maneuvers within and onto the state highway right-of-way are strictly prohibited. Att
vehictes shatl enter and exit the highway n'ght-of-way in a forward movement. Bicking into the
right-of-way shatt be considered a violation of the Terms and Conditions of the Access Permit and
may resirlt in the revocation of the permit by CDOT and/or lssuing Authority.
14. The Permittee assumes responsibitity for any and atl easements that are associated with this
access. lf an easement is part, of this access permit, CDOT shatt not be tiabte for incorect
information in the easement documentation and it's the permittees responsibitity to ensure atl
applicable laws and regutations have been fottowed.
DocuSign Envelope lD: DEB35D79{E6D-4555-BD2E-CF5058685526
EOLOR,ADO
Departmcnt of
Transportation
What is stormwater runoff?
Stormwater runoff occurs when precipitation from rain or snowmelt
flows over the ground. lmpervious surfaces like roads and sidewalks
prevent stormwater from naturally soaking into the ground
Why is stormwater runoff a problem?
Stormwater can pick up debris, chemicals, dirt and other
pollutants and flow into CDOT'5 storm drain system or directly
into a stream, river, lake, wetland or reservoir. Anything that
enters CDOT'5 storm drain system is discharged untreated into
the waterways we use for fishing, swimming, and providing
drinking water.
Tips for Reporting an lllicit Discharge
Call the illicit discharge hotline at (303153,2'4426
From a safe distance try to estimate the amount of
the discharge.
ldentifo characteristics of the discharge (color, odor,
algae, etc.).
Obtain information on the vehicle dumping the
waste (if applicable).
Do not approachl
Call *CSP for illicit dumping.
lf possible, take a photo, record a license plate.
i.li: i'"i {: i ll l":) l: 'i '
For more information on CDOT Utility
Permits:
:111-11.,.,-,i1,_r'. Lcl i:[-..:L\, iJl:,. 1 .,. J\] ::"../'-i: t:
!!!c t:i,ii:r.:
For more information on CDOT Access
Permits:
e0tQRApffi
Departrnent of
Transportation
li'ater Qualitv Drograrn
lnrlustrial Facilities
[rrograrn
CDOT has a Municipal Separdte Storm Sewer System permit,
othenruise known as (MS4) from the Colorado Department of
Public Health and Environment. The permit states that onlv
stormwater can be discharged from cDoT's storm drain system
crrdbarin
ffi
rewerpipe*
TO IHE WASIIWAIER
NEATIIEiIT PTANT
pl9s*
TollE rocAr
WAT€NBODY
l1i 1r1,, /isr1vlrr r i:rin I p O u / i;t rsr rrrr\i': rlrr i ril it !/.ril at i'l
As part of the permit, CDOT hos several dffirent
programs to prevent pollutants from entering into
the storm drain system:
Construction Site Program
New Development Redevelopment Program
lllicit Discharge Program
lndustrial Facilities Program
Public Education and Outreach Program
Pollution Prevention and Good Housekeeping
Program
Wet Weather Monitoring Program
3i: i irr it,{
For more information on CDOT Water Quality
Program:
Water Quality Program Manager
420I E. Arkansas Ave.
Shumate Buiiding
Denver, Colorado 80222
303-75 7,9343
Dredged spoil. dirL slurny, solid waste, incinerator
residue, sewage, servage sludge, garbage, trash,
chemical waste, blological nutrient, biological
material, radioactive material, heat, pH, wrecked or
discarded equiprnent, roek sad, any industrial,
municipal, or agricultural waste.
DocuSign Envelope tD: DEB35D79-0ED4S5S-BD2E-CF50SB68SS26
EOtORADCI
, Department of
, Transportation
Control Measures
for lndustrial
Facilities
lndustrial facilitles can use control measures (CM)
otherwise known as Best Management practices
(BMP) during the construction of a facility and when
operating the facility. Control measures are schedules
of activitiet maintenance procedures, and other
management practices to prevent and reduce
pollution entering into CDOT's storm drain system.
&ntrol Measures also include Featmert, operating
proceduret and practices to control site run off
which can include structural and non-structural
controls.
Tl{f;' frAlTil"r": gT
an€ n€ne
9CUUreR?
6 TREnt A 8i'P
PR'SENT?
CDOT defines a utility, or utility facility as any
privately, publicly,, or cooperatiTely owned
line, facility, or system producing, transmitting
or distributing the following:
/ Communications
/ Cable television
{ Power
/ Electricity
r' ticht
/ Heat Gas
/oil
/ CrudeProducts
/ Water
/ Stream
/ Waste
/ Stormwater not connected with highway drainage/ Similar Commodity
COLffiR,ADO
I Department of
Transportation
lndustrial Facilities Program Elements:
1. Educate and outreach to owners
or operators that have potential to
contribute substantial pollutant to
water.
2. Report and include information on
discha6e and water quality
concerns. Provide written
notification within 15 days of
discovery to CDPHE.
3. Submit an annual report to CDPHE
containing the number of
informationat brochures
distribubd; name and title of each
individual trained.
Education
There are instances when a utility
company or other entity doing work in the
state highway right-of-way will require
some type of environmental permit or
clearance for that urork. CDOT has put
together an Envi:-onrnental Clearances
lnformation Summary for those applying
for a CDOT Utilitv anC Special Use permit
or Access Permit to obtain all required
clearances. This fact ;heet is given to each
permittee and is available at:
i t !p.,1 i wUlW.! llllg31 9 d 9 !., i y
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DocuSign Envelope lD: DEB35D79-0EGD4555-BD2E-CF5058685526
COLORADO DEPARTMENT OF TRANSPORTATION
Environmental Glearances lnformation Summary
PURPOSE - This summary is intended to inform entities external to CDOT that may be entering the state highway right-of-way to
perform work related to their own facilities (such as Utility, Special Use or Access Permittees), about some of the more commonly
encountered environmental permits/clearances that may apply to their activities. This listing is not all-inclusive-additional
environmental or cultural resource permits/clearances may be required in certain instances. Appropriate local, state and federal
agencies should be contacted for addilional informalion if there is any uncertainty about what permits/clearances are required for a
s[ecific activity. IMPORTANT: Please Review The Following Information Carefully - Failure to Comply With Regulatory
Requirements May Result ln Suspension or Revocation of Your CDOT Permit, Or Enforcement Actions By Other
Agencies.
CLEARANCE CONTACTS - As indicated in the permiVclearance descriptions listed below, the following agencies may be
contacted for additional information :. Colorado Department of Public Health and Environment (CDPHE): General lnformation - (303) 692-2000
Water Quality Control Division WaCD): (303) 692-3500
Environmental Permitting Website https;/lu$d.colorado.gov/pacificlcdph.elall-p.ermits
. CDOT Water Quality Program Manager: (303) 5124053 htlpell/www.godqt.qovlproqramslenvirqnryentaUwater-qqality. CDOT Asbestos Project Manager: (303) 512-551 Ir Colorado Office of Archaeology and Historic Preservation: (303) 866-5216
. U.S. Army Corps of Engineers, District Regulatory Offices:
Omaha District (Northeastem CO), Denver Office (303) 9794120
http://www.nwo.usaqe.arnty.&il1Mlqg1-ens/RegulatoryProqlc11/g{-q.adp-ecgx
Sacramento District (Western CO), Grand Junction Office (970) 243-'1199
!:ltplAuryw-sl&.u q @ q I a to ry.' a sp x
Albuquerque District (Southeastern CO), Pueblo Office (719) 543-9459
htlp/lqrywfpaUSg_qg..arr:rrv.tnil/Missiong/RequlatoryProqramandPermits,aspx
lCDoTUtilities,SpecialUseandAccessPermitting:(303)757.9654
Wildlife Resources - Disturbance of wildlife shall be avoided to the maximum extent practicable. Entry into areas of known or
suspected threatened or endangered species habitat requires special authorization from the CDOT permitting office. lf any
threatened or endangered species are encountered during the progress of the permifted work, work in the subject area shall be
halted and the CDOT Regional Permitting Office and Region Planning and Environmental Manager shall be contacted
immediately. Authorization must be provided by CDOT prior to the continuation of work. lnformation about threatened or
endangered species may be obtainod from the CDOT website, h!!p://wWw.codqt.qovlproqrams/environmenlallwildlife/guidglines, or
the Colorado Parks and Wildlife (CPW) website, lrttp://www.cpw.state.co,us/legI!/Paqe-grsOC-JhreatenedEndanggredLjst.aspx.
Additional guidance may be provided by the appropriate Region Planning and Environmental Manager (RPEM).
Cqltural Resources - The applicant must request a file search of the permit area through the Colorado Office of Archaeology and
Histo*c preservition (OAHP), Denver, to ascertain if historic or archaeological resources have previously been identified
(https://www.histqfycolorado.orq/file-Agcess_; 303-866-5216). lnventory of the permit area by a qualified cultural resources
specialist may be necessary, per the recommendation of GDOT. lf archaeological sites/artifacts or historic resources are
encountered Ls the project progresses, all work in the subject area shall be halted and the CDOT Regional Permitting Office and
Region Planning and Environmental Manager shall be contacted immediately. Authorization must be prgvtded by CDOT prior to
the continuation of work. Additional guidance may be provided by the Regional Permitting Office and RPEM.
Paleontoloqical Resources - The level of effort required for paleontological resources is dependent on the amount of ground
disturbance, including rock scaling, digging, trenching, boring, ground leveling, and similar activities,
. lf the permit will involve extensive ground disturbance (generally involving more than one mile of CDOT ROW), a full review
will be required by a qualified paleontologist, including map, flle, and locality searches, with final recommendations provided by
the CDOT paleontologist upon receipt of the report. Based on results of the review, a survey or inventory of the permit area
may be necessary.r lf the permit will involve a small amount of ground disturbance (less than one mile of ROW), the applicant must request a fossil
locality search through the University of Colorado Museum of Natural History (hlJpsl//www,cqlEado.edulc-Uquseqn/resgarch-
SalCg1iSlg&aleontolocly/golid ) and the Denver Museum of Nature and Science
(nL Letce/earth-qcienceslearth-s_qie{rceq-collections/). The museum collections managerwill provide
information about localities in the project area. lf there are no known localities, the permit requirement for paleontology is
complete upon submitting that information to CDOT. lf there are known localities, the CDOT paleontologist will be contacted
by the museum with delails, and additional recommendations will be made if necessary. Note that museum staff are not
required to disclose the details of fossil localities to the permit applicant, nor is detailed locality information required for the
permit application to proceed.
. lf the permit does not involve ground disturbance, no action is required for paleontological resources. lf fossils are
encountered during the permitted action, all work in the immediate area of the find should stop and the CDOT Staff
Paleontologist and the Region Environmenlal Manager should be contacted immediately. Authorization must be provided by
CDOT prior to the continuation of work. Additional guidance may be provided by the Regional Permitting Office in the Permit
Special Provisions. Contact lnformation: See the museum websites listed above. The CDOT Paleontologist is not able to
conduct locality searches independently. For further information contact CDOT Paleontologist Nicole Peavey at
n icole.peavey@state.qq.gq or (303) 7 57 -9632.
Environmental Clearances lnformation Summary Page 1 of3 Colorado Department of Transportation July 2020
DocuSign Envelope lD: DEB35D79"0EOD4E5S-BD2E-CF50SB68SS26
TransPortatlon of Hazardous Materials - No person may offer or accept a hazardous material for transportation in commerce
unless that person is registered in conformance with the United States Department of Transportation regulations at 49 CFR, part
171 . The hazardous material must be properly classed, described, packaged, marked, laboied, and in Condition for shipment as
required or authorized by applicable requirements, or an exemption, approval or registration has been issued. Vehicles requiring a
placard, must obtain authorization and a State HMMAT Permit from the Colorado Public Utilities Commission. Contact
lnformatlon: For authorization and more info call the Federal Motor Safety Carrier Administration, US DOT for inter- and intra-
state HAZMAT Registration (303) 969-6748. Colorado Public Utilities Commission: (303) 894-2S68.
- Clean Water Aet seelion 404 permits are often for the
discharge of dredged
including nationwide,
I into waters of the U.S., including wetlands. Several types of section 404 permits exist,
regional general, and individual permits. Nationwide permits are the most commonly authorized type for
activities with relatively minor impacts. lf an individual 404 permit is reqrrired, section 401 waler qtrality certification from the
CDPHE WQCD is also required. Contact the appropriate Corps District Regulatory Office for information about what type of 404
permit may be required (contact information above).Contact th e CDPHE Water Quality Control Division at (303) 692-3500.
or fill
Working on or in,qnv-stream or its bank - ln order to protect and preserve the state's fish and wildlife resources from actions
that may obstruct, diminish, destroy, change, modify, or vary a natural existing stream or its banks or tributaries, it may be
necessary to obtain a Senate Bill 40 certification from the Colorado Department of Na'.ural Resources. A siream is defined as 1)
represented by a solid blue line on USGS 7.5' quadrangle maps; and/or 2) intermittent slreams providing live water beneflcial to
fish and wildlife; andlor 3) segments of streams suppor.ting 25o/o or more cover within 100 yards upslream or downstream of the
project; andlor 4) segments of streams having wetlands present within 200 yards upstream or downstream of the project measured
by valley length. The CPW application, as per agreed upon by CDOT and CPW, can be accessed at
Erosion and Sediment Control Practices - Any activities that disturb one or more acres of land require a Stormwater
Conslruction Permit (SCP) from the CDPHE-WQCD. Erosion & sediment control requirements will be specified in that permit. ln
situations where a stormwater permit is nof required, all reasonable erosion and sediment control measures should be taken to
minimize erosion and sedimentation. Control practices should be in accordance with CDOT Standard Specifications 107.25,2A8,
213 and 216 (lrtlps:/lr4 vw.cgdot gqv/bUsiness/de$lSnqgppA$!{o_LgSlglltJ9tjglt:qp_gAifieAllens). The CDOT Erosion Controland
Stormwater Quality Guide (website: bttpg/ sl.o-tm:q.uAlity)
can also be used to design erosion/sediment controls. Contact lnformation: Contact the CDPHE-WQCD at (303) 692-3500.
Wehsite: ltljnS/uanry-eebta d n.gl'/"hggtf ic/cd pb elwq:eonsirug]j.q g!-slel:pelm1g,
Site Stabllization - All disturbances require a stabilization plan, native seeding or landscape design plan according to applicable
CDOT Standard Specifications 212-217 and 623. The CDOT Erosion Control and Stormwater Quality Guide should also be used
to plan restoration of disturbed vegetation. Website: !:ltpglU4ryW_aSdSlggy/plqS€lx$&ng$$entaUlqrylscql$:.@lly
Stormwater Discharqe From Industrial Facilitles - Discharges of stormwater runoff from certain types of industrial facilities, such
aE concrete batch plants - require a CDPS Stormwater Permit. Contact lnformation: Contact the CDPHE-WQCD at (303) 692-
350U. Website: https/qglEAdo.govlpacific/c_dphe/wa-QorInlgjgq-and:industrv-perrnils
Concrete Washout - Waste generated from concrete activities shall NOT be allowed to flow into the drainage ways, inlets,
receiving waters, or in the CDOT ROW. Concrete waste shall be placed in a temporary concrete washout facility and must be
located a minimum of 50 feet from state waters, drainageways, and inlets. Concrete washout shall be in accordance to CDOT
specifications and guidelines at https/wwweS_dst-sovgt,$jtesddeqjs.ng!epS!V-adg!a9!q-ttla!9!!-9p"9dla-a!9!S and refer to the
specifications and their revisions for sections 101, 107 and 208.
Construction Dewaterina (Discharqe or lnfiltration) and Remediation Activities - Discharges of waler encountered during
excavation or work in wet areas may require a Construction Dewatering or Remediation Activities Discharge Permit. Contact
Environmental Clearances lnformation Summary Page 2 of 3 Colorado Department of Transportation July 2020
DoquSjsn Envelope lD: DEB35D79-0EOD-4555-BD2E-CF5058685526
lnformatlon: Contacl the CDPHE-WQCD at (303) 692-3500. For Applications and lnstructions:
https://www.colorado.qoy,ipaqificlcdphg/wg-constructigg-genelal-permits.
Municipal Separate Storm Sewer Svstem (MS4) Reouirements - When working in a MS4 area, discharges to the storm sewer
system are subject to CDOT's or other municipalities' MS4 Permit. For activities within the boundaries of a municipality that has a
MS4 permit, the owner of such activity should contact the municipality regarding stormwaler related requirements. All discharges
to the CDOT highway drainage system or within the Right of Way (ROW) must comply with the applicable provisions of the
Colorado Water Quality Control Act, the Water Quality Control Commission WOCC) Regulations
(https/lvrryWe,olq6Qo.qov/p.acj{iclcdp-he/woccjeqUh_tiggF-gf}d-pgli-qpggld.-water-qualitv-statutes) and the CDOT MS4 Permit
#COS-000005 (t]!!Bs://www.codot.qo_vi:B-Loqrams/envirEUnental/waler-qualitv/documerylg). Discharges are subject to inspection by
CDOT and CDPHE. For CDOT-related MS4 programs and requirements, go to:
iltps:i/www.codot.gov/programs/FnVironmental/water-qLtality/gtoLmwgter-plograJ.ns,
Post-Construction Permanent Water Qualltv - When working in a CDOT MS4 area and the activity disturbs one or more acres,
permanent water quality control measures may be required. lnformation on the requirements can be found under the CDOT
Permanent Water Quality MS4 Program at: b!lpSl@!{'cSdglggv&rogra.mslenvironmentallwatgr:guqlihrlstgrmwaler-
preqi"a ms/nwq-p erman ent:yvatgJgu alily
Discharqes to Slorm Sewer Svstems
Prohibited Discharqes - All discharges are subject to the provisions of the Colorado Water Quality Control Act and the Colorado
Discharge Permit Regulations. Prohibited discharges include, but are not limited to, substances such as wash water, paint,
automotive fluids, solvents, oils or soaps and sediment.
Alo.yable Discharqes - The following discharges to stormwater systems are allowed without a permit from the CDPHE'WQCD:
landscape irrigation, diverted stream flows, uncontaminated ground water infiltration to separate storm sewers, discharges from
potable water sources, foundation drains, air conditioning condensation, irrigation water, uncontaminated springs, footing drains,
water line flushing, flows from riparian habitats and wetlands, and flow from firefighting activities, Contact lnformation; Contact
the CDPHE-WQCD at (303) 692-3500. lnformation can also be found in the CDOT lllicit Discharge MS4 Program PDD at:
llttAs://www.qqdot..s-ov/nrogra{ns/envirory}tental/wa!er-guality/stormwater-proqramslidde.html.
Spill Reportinq - Spills shall be contained and cleaned up as soon as possible. Spills shall NOT be washed down into ihe storm
drain or buried. All spills shall be reported to the CDOT lllicit Discharge Hotline at (303) 512-4426 (4H20), as well as the Regional
Permitting Office and Regional Maintenance Supervisor. Spills on highways, into waterways, any spill in the highway right-of-way
exceeding 25 gallons, or that may othenrise present an immediate danger to the public shall be reported by calling 91 1, and shall
also be reported to the CDPHE al1-877-518-5608. More information can be found at
https:./lwww.cqlorado.qoUlpaci-tc/cd pheleFergg[cy+epor.ting-li ne.
Disposal of Drillinq Fluids - Drilling fluids used in operations such as Horizontal Directional Drilling may be classified as
"discharges" or'solid wastes," and in general, should be pumped or vacuumed from the construction area, removed from the State
Highway Right of Way, and disposed of at permitted facilities that specifically accept such wastes. Disposal of drilling fluids into
storm drains, storm sewers, roadside ditches or any other type of man-made or natural waterway is prohibited by Water Quality
Control and/or Solid Waste regulations. Small quantities of drilling fluid solids (less than 1 cubic yard of solids) may be left on-site
after either being separated from fluids or after infiltration of the water, provided: 1) the drilling fluid consists of only water and
bentonite clay, or, if required for proper drilling properties, small quantities of polymer additives that are approved for use in
ddnking water well drilling; 2) the solids are fully contained in a pit, and are not likely to pose a nuisance to future work ln the area,
3) the solids are covered and the area restored as required by CDOT permit requirements (Utility, Special Use, or Access Permits,
etc.). Confact lnformation' Contact CDPHE (telephone #'s listed above).
Noxious Weeds and lnvasive Species Manaqement Plan - Noxious Weeds and lnvasive Species guidance can be found by
contacting the Colorado Department of Agriculture (https;/u v-w.c.!r!grado-.qov/oacific/aqconservationinoxiousweeds) and the
Colorado Division of Parks and Wildlife (http://cpw.slate.co.us]aboutus/Pages/RS-NoxiousWee-ds.aspx). ln either case,
management plans involving the control of noxious weeds associated with the permitted activity and cleaning of equipment will be
required.
Environmental Clearances lnformation Summary Page 3 of 3 Colotado Department of Transportation July 2020
I D : DEB35El79-0EOD-4555-BD2E-CF5058685526
t
DocuSign Envelope tD: DEB35D79-0EGD-4555-BD2E-CF5058685526
COLORADO DEPARTMENT OI- 1'RANSPORTATION
STATffi hff$GF{WAV ACCESS PHR$MflT' APPI.ICAT$ON
lssuing aullror ity applicalion
accelllance dale
Sul}]rrl an al)plicnlion lor eaclr access alfeclerl
ll you lraVe arry queslir-rns {:onlacl tlte issttin0 aulhcrily.
Foraddi{ionalrrllottrtaltonseecDoT'sAcccssMan.'.gentetrlwcbsitcat
l!rsll trclrotls:
Please print
or lype
l) Propcrly owncr (Pertnitlce)
't t rri. f iri.r, ria i. {.,;-l -' ui.l :ir.;
rl 0[poiltr rl propcr ly ovJncr )
address
: .r,i i jrJr.:ll t.r,i :{ilii,-i -:,1 t,
City. slate & zip Phone lt slate &zill Phone j/ (r'equir'ed)
.itlr t.'O 111,,.i,,:tj ,'{l I,i i,i,lrl.l
E-rnarladdress
',.l,rli11 r.()il :r 2 :ti i,/ -t i:,,,-i . i :1: i::r
address il irvarlable
3) A(ldrcss ol propcrly lo l)c scrved by (raquireditlrll l llil
/"r), I r./*- ',))' i fj i(" rr 1v1 "C ,.J ii',i-' ,i nll,, , ( ,t ^i 1", ('.r' t'ii i. '/ .]
4) Leoal desctiptiott of ptoperly: llwiihirr irtlrsclrt;liotr fvlLlrrrcipalily. cilv irr rd'or' County, r.vlrrch orre?
c.!\i'ri r sulr(lrvr.toil
1.. .. .r:r:.:.:|:,.1 Il:.lriiri, it
trlocl
I
l0t toclrotr lo?inshrl)
5) Whal Slate Flighlvay are yorr requestirrgl nccess lrortt?
llr-{Jlrltir\,/ ( lii.'rCt: ir'r',::lii.;iqe 1l{)i,.i
7i tlow nlany leet is prol:osed access flonl the tlcaresl rrtile post?How rnarty feel is lhe proposecl acces.s lronr lhe nearesl cross strecl?
)?N feel []ryr
6) Whar side o{ the
IN
hiohwav?Es'EE nw
N lronr
date inlond lo conshriction?
E 0 l s EC5 il\l(i: j.j;1),r: 1.\-\r i:rlr;-j t-lt ai-r:,:
B)Wlra rs the approxl nrate you
a,,/ -l 0 r, ",] il:l t
9) Check lrere if you are requBsling a
new access f]tcnrporary acccss
charrge irt access uge
{duraiion anticipate(l:
l-lrentoval of access
ffi inrprorgr,errl lo exislin0 acocss
f]'elocalion ol arr exislln-t; access {provide detail)
10) Provide existing properly use
ititt i t.rri.l-t:tl:t-,:r.i. rrt:r.! ill,i :!
flno I V0s. it yes - wlral aro tlre pe r rril rlur.r]ber (9) i1n(J prot/icle copies: anci/or. fjerntii date
1 2) Does lhe prope
Ino
ovvr]er ovvn or hA'rc Alry intetesls in any adiaCent l)roperly?
yes. il yes - please descril)e:.i.,... i-r:rr irl:rri:){)}r i.\,
Eloo f]Ves. rt yes - lisl tlrcrrr orr your plans and indicale llte lrroPosed and existing access poittls.
I 41 ll yor.r are rcqtreslirrg ilgricullur-tl lield ncoess - ltow rtttrry actcs vrrll lll€ ltccess serte?
bLrsir.lcss;larrd usc f,o!r-tgg.u-busrncgs __ _ _.-9,ClSl9_19.9!iS9
I
._ -_ _,..,i-__
16) ll you ale requesttng resrdenlial developonlont access, vvhat is the iype (srngle f anrily, aparlnlerlt. townhousq) and rlurnber of urrrtg?
lype ntttnber of unils lYPe rnlrnber of unils
: ,.' r,'i i : ;' ;,trl i ! .,
!
i',rl l)4strriU/jr L:nr', .t,rl ljr.Jlrl:!ttL!.!.ii lrj.:t: lruJr r'\,lnr,r':!i
r ,)l !it,nr L.,tr'.lrrs lrrld r:'lrittr:,prt
'.illlr irlr! lrJr.li:t ai plark lnjur /ol,r(a:llndrcale il ycur 0ounls ar(:)
horrt trolurttes or a'relaUe clar
ri oi sul:lc l.ri rll.rcl4s rn,rr.trsi rli -ta Total count ot all vehicles
Prcvious editions are obsoletc arrrl nray not be used Pagc 1 o, 2 CDOT Fornr lrl 37 1 2l l 8
a) Prclperly firap irrdicaling othe! acccss, llor(ieilnq roads artLl slreel$.
b; lirglrway anci drivr:lvay 1:lan prolile.
c) Dr ainage plan showilrg rrnpacl lo the highr.,ray r ighi-of -trayr.
d) F,4ip arrd lelters eletailinU utilily locetions br:forc anrJ alte r
Cevlrloplnenl in and alonq llte rifllrl Ol'way.
e) Subdivision. :orrirrg. or dcvelolnlrent plan.
l) Proposeri accessck;sigri.
g) Parcel and orvrrctslrip rnaps irrdtrclirrq casenlenls.
Ir) Traffic stucjics.
ii l)[ool ol o\,inrerslilp.
1- ll is the applicant's responsibility to contact appropriate agencies at'ld obtain all envirorrmenlal cleararlces that apply to
tlteir activitie.c. {iuch clearanc,e$ ntay inr.lt rcle Corlrs of Errgirieers 404 Pr--rrrriiLs ur Colutalh' Disrjl rarU'j P*rrnit ,systerrr
permits, or ecological, archeological, historical or cultural resoutce clearatlces. The CDOT Environmenlal Clearances
Ittformatiott Sutttmaty ptesents contact lnlormation for agencies admririslerirrg cettain clearances, information aboirl
prohibited discharges, and ll'lay be obtained frorn Regional CDOT Utility/Special Use Perrnil offices or accessed via the
CDOT Planning/Coustruclion-Environrnertlal-Guidance webpage: lrJtps://www.codol,gov/programs/envi-ronmentqU
resoli[9e9/guidance-standarclgbqvironmentq!:g!eerances-info-sunllary:qHqu,st-2017/vie!ry
2- All worl<ers within the Stale Highway righl of way slrall comply with their employer's salety and health policies/
procedures, and all applicable U.S. Occupational Safety and Healtlr Admirristration (OSHA) regulations - irrcluding, but not
litnited to the applicable sections of 29 CFR Part 1910 - OccLrpaliorralsafety arrd Health Standards arrd 29 CFR Part 1926
- Safety and I lealllr Regulalions for Corrstructiorr.
Personal protective equipment (e.9. head lrrotection, footwear, high visibility apparel, safety glasses, lrearing protection,
respirators, gloves, etc.) shall bc worn as appropriate for the worl< beirrg per{orrned, and as specified in regulatiorr. At a
minitnum, all wotl<ets in the State Highway righl of way, except wlren in their velricles, shall wear the followirrg personal
protective equipntent: High visibility apparel as specilied irr the Tralfic Control provisions oI lhe docurnentation
accomparrying tlte Notice to Proceed related to lhis perrnit (al a rrrinirrurn. ANSI/ISEA 107-1999, class 2), head protecliorr
that complies with the ANSI 289.1-1997 standard; and al all constrlrction sites or wherlever tlrere is danger of injury to
feel, workers sltnll comply with OSHA's PPE requirerrerrts for foot prolection per 29 CFR 191 0.1 36, 1926.95, and
1926.96. lf tequired, suclr foolwear shall rreetlhe requirernenls o1ANSI 241-1999.
Wltere any of tlre above-reiererrced ANSI standards have been revised. the tnost recetrt version of the standard shall
apply.
3- The Permltlee is responsible for complying witlr the Revised Guidelirres tlrat lrave been adopted by lhe Access Board
lniar tha A mnrina," F\irrhilitina Ant / A l-\ AII-l"a-^ ^,,i.1^1i,.^.. ,{^{i,.^ 1,4\,^raahla nlann rnar rirnrran}o anrl nvannviha lt-'a r rnnurrv9r lrrs nrrrsrruorr uroouillLrgo nul \nun,/. r rtGJg uurvEltrq) ucnrtE (t(vgr)4utg JrUPE rsvlrn(-r,lErrlJ arru PrgJUrrus rrrv Lrru
of a deiined palterrr ol truncated dornes as delectable warnings at street crossit')gs. The new Starrdards Plans and can be
found on the Design and Conslruction Prolect Slrpport web page at:
https ://www.codot. gov/busi ness/civilrights/adalresou rces-engi neers.
DocuSign Envelope lD: DEB35D79-0E0D4555-BD2E-CFS0SB6BSS26
lf an access permil is issued to you, it will slate the lernrs and conditiorrs {or its use. Any clranges in the use of the
petmitted access rrol corrsistenl with the terrns arrd cor']ditions listed on tlre pernrit nray be considered a violaliott of tlre
permit.
The applicant declares under penalty of perjury in the second degree, and any other applicable state or federal
laws, lhat all information provided on this form and submitted attachments are lo lhe best ol their knowledge
true and complete.
I understand receipt of an access perrnit does not constitute permission to start access construclion worl<.
Applicanl or Agerrt ior Perrllllec sr(lrralure Dale
lf the applicant is rrol the owner ol tlre
their legally autltorized rcpreserrtalive
with lltis applir:atiorr hy all nwners-o{-i
cases, will be listed as tlre pernrittee.
property, we require this application also to be signed by lhe properly owrtel ol
(or olher acceptable written evidence). -lhis signature shall constitule agreentent
nleresi nt'lless slaled irr writing l{ a perrnit is isstred, lhe properly owner, in ntost
Print natnc DaleProfrurly ()wrref rUrratrrrc/ i.//,/,/, *,,/0t, /iq/ r:
Previor.ls editions ere obsolete and may nol be uscd Paqc 2 ol 2 CDOT Forrn 11137 12118