PermitApplication.pdf

COLORADO DEPARTMENT OF TRANSPORTATION

UTILITY/SPECIAL USE PERMIT APPLICATION

Permittee: property or utility owner Name

Address

Contact person e-mail address Telephone

Applicant if other than permittee Name

Instructions:

Complete this form, attach all required documents, and submit it to the appropriate permit office. To determine which documents are required, refer to page 2 of this form and/or contact the Permit Office. You must submit all required documents or the application will be deemed to be incomplete and will not be accepted. Please do not FAX completed forms or documents.

Please print or type

Address

Contact person e-mail address Telephone

Activity Description: (furnished by permittee)

Purpose of Utility Permit ❑ Installation ❑ Adjust/relocation ❑ Removal ❑ Maintenance of existing facility

Facility (type, size, class of transmittant, design pressure or potential, etc.

Nature of installation ❑ Longitudinal (parallel) ❑ Buried* ❑ Aerial/Ground-mounted ❑ Transverse (crossing) ❑ Attach to Highway Structure #:

Location relative to SH milepost(s)

Additional remarks

If Permittee will own or operate underground facilities in State Highway rights-of-way: Indicate contact person for underground location information:

Telephone

*Notice to Excavators: Pursuant to 9-1.5-103 C.R.S., excavators shall not make or begin any excavation without first notify-ing the Utility Notification Center of Colorado (UNCC) and if necessary, then notifying the tier two members having under-ground facilities in the area of such excavation. Notification shall also be given to the CDOT regional permitting office, or as otherwise directed by the Special Provisions of the permit that is issued. Notice of the commencement, extent and duration of the excavation work shall be given at least two business days prior thereto, not including the day of actual notice. The UNCC may be called at 1-800-922-1987.

See reverse side for additional instructions

State Highway No. County City/Town

Purpose if for other than Utility Permit

❑ Landscaping ❑ Survey ❑ Spill cleanup ❑ Site restoration ❑ Construction within right-of-way ❑ Other (describe):

Location relative to intersecting feature(s), e.g., cross street, str. #, etc.

Intended start date and planned duration of work

Previous editions of this form are obsolete and may not be used Page 1 of 4 CDOT Form #1233 10/07

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

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.

Application requirements - submit with completed application form

Previous editions of this form are obsolete and may not be used Page 2 of 4 CDOT Form #1233 10/07 http://www.dot.state.co.us/environmental/forms.asp

A. The Permittee shall obtain and maintain insurance at all times during the performance of work authorized by the Permit, in the following kinds and amounts. The Permittee shall require any Contractor working for them within the State Highway Right of Way to obtain like coverage. The Permittee shall also require any Contractor or Consultant performing work described in sub-paragraph 4) below, to obtain Professional Liability Insurance.

1) Workers’ Compensation Insurance as required by state statute and Employer’s Liability Insurance covering all employees acting within the course and scope of their employment and work on the activities authorized by the Permit.

2) Commercial General Liability Insurance written on ISO occurrence form CG 00 01 10/93 or equivalent, covering premises operations, fire damage, independent Consultants, products and completed operations, blanket contractual liability, personal injury and advertising liability with minimum limits as follows:

a. $1,000,000 each occurrence;

b. $2,000,000 general aggregate;

c. $2,000,000 products and completed operations aggregate; and

d. $50,000 any one fire.

e. For any permanent Permittee-owned installations located within the State Highway Right of Way, highway repairs, or site restoration, Completed Operations coverage shall be provided for a minimum period of one year following final acceptance of work.

If any aggregate limit is reduced below $1,000,000 because of claims made or paid, the Permittee, or as applicable - their Contractor shall immediately obtain additional insurance to restore the full aggregate limit and furnish to CDOT a certificate or other document satisfactory to CDOT showing compliance with this provision.

3) Automobile Liability Insurance covering any auto (including owned, hired and non-owned autos) with a minimum limit as follows: $1,000,000 each accident combined single limit.

4) For any: a) engineering design; b) construction inspection; or, c) traffic control plans approved by a Traffic Control Supervisor; done in association with the operations or installations authorized by the permit, Professional Liability Insurance with minimum limits of liability of not less than $1,000,000 Each Claim and $1,000,000 Annual Aggregate. If the policy is written on a Claims Made Form, the Permittee, or, as applicable – their Consultant or Contractor, shall renew and maintain Professional Liability Insurance for a minimum of two years following final acceptance of the work, or provide a project specific Policy with a two year extended reporting provision.

5) Pollution Legal Liability Insurance with minimum limits of liability of $1,000,000 Each Claim and $1,000,000 Annual Aggregate. CDOT shall be named as an additional insured to the Pollution Legal Liability policy. If the Policy is a component of the Professional Liability Policy, the Additional Insured requirement is waived, and the Policy shall be written on a Claims Made Form, with an extended reporting period of at least two year following final acceptance of the work.

6) Umbrella or Excess Liability Insurance with minimum limits of $1,000,000. This policy shall become primary (drop down) in the event the primary Liability Policy limits are impaired or exhausted. The Policy shall be written on an Occurrence form and shall be following form of the primary. The following form Excess Liability shall include CDOT as an additional insured.

Previous editions of this form are obsolete and may not be used Page 3 of 4 CDOT Form #1233 10/07

COLORADO DEPARTMENT OF TRANSPORTATION

INSURANCE REQUIREMENTS FOR CDOT UTILITY AND SPECIAL USE PERMITS

B. CDOT shall be named as additional insured on the Commercial General Liability and Automobile Liability Insurance policies. Completed operations additional insured coverage shall be on endorsements CG 2010 11/ 85, CG 2037, or equivalent. Coverage required by the Permit will be primary over any insurance or self-insurance program carried by the State of Colorado.

C. The Insurance shall include provisions preventing cancellation or non-renewal without at least 30 days prior notice to CDOT by certified mail.

D. The Permittee, or, as applicable – their Contractor or Consultant, will require all insurance policies in any way related to the Permit and secured and maintained by the Permittee, Contractor or Consultant, to include clauses stating that each carrier will waive all rights of recovery, under subrogation or otherwise, against CDOT, its agencies, institutions, organizations, officers, agents, employees and volunteers.

E. All policies evidencing the insurance coverage required hereunder shall be issued by insurance companies satisfactory to CDOT.

F. The Permittee, or as applicable - their Contractor or Consultant, shall provide certificates showing insurance coverage required by the Permit to CDOT prior to commencing work. No later than 15 days prior to the expiration date of any such coverage, the Permittee, Contractor or Consultant, shall deliver CDOT certificates of insurance evidencing renewals thereof. At any time during the term of this contract, CDOT may request in writing, and the Permittee, Contractor or Consultant, shall thereupon within 10 days supply to CDOT, evidence satisfactory to CDOT of compliance with the provisions of this section.

G. Notwithstanding subsection A of this section, if the Permittee is a “public entity” within the meaning of the Colorado Governmental Immunity Act CRS 24-10-101, et seq., as amended (“Act’), the Permittee shall at all times during the term of this permit maintain only such liability insurance, by commercial policy or self-insurance, as is necessary to meet its liabilities under the Act. Upon request by CDOT, the Permittee shall show proof of such insurance satisfactory to CDOT. Public entity Permittees are not required to name CDOT as an Additional Insured.

H. If the Permittee engages a Contractor and/or Consultant to act independently from the Permittee on the permitted work, that Contractor and/or Consultant shall be required to provide an endorsement naming CDOT as an Additional Insured on their Commercial General Liability, Auto Liability, Pollution Legal Liability and Umbrella or Excess Liability policies.

Previous editions of this form are obsolete and may not be used Page 4 of 4 CDOT Form #1233 10/07

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setdistillerparams /HWResolution [2400 2400] /PageSize [612.000 792.000] >> setpagedevice