NMDOT_A-066TrafficControlRoadwayWorkPermit.pdf

Form No. A-66 New 03/13

NEW MEXICO DEPARTMENT OF TRANSPORTATION

(NMDOT)

TRAFFIC CONTROL/ROADWAY WORK PERMIT

NMDOT Project Number (If applicable): Control Number:

General Scope of work:

Contractor Name:

Contact Person:

Contact Telephone: ( ) - Fax: ( ) -

Traffic Control Firm:

Certified Traffic Control Supervisor:

Contact Telephone: ( ) - Fax: ( ) -

Work Zone Location Information:

Route:

Mile Post: From To:

Or Intersection: Intersection:

Direction (NB, SB, EB, WB, or both):

2 lane Road 4 lane Road 6 lane Road 8 Lane Road Divided Undivided Existing Speed limit in area: ___ MPH or Ranges from ___MPH to ___MPH Proposed Speed Limit reduction within work zone (If Applicable):______________ MPH

Working Duration:

Start Date: End Date :_______________________________ Daily Start Time End Time:

Purpose of Permit: Roadway Construction/Rehab. Shoulder Work Signal and Lighting Work Utility work Drainage/Excavation work Soil Testing Signing and Striping Placement

Other:

TCP Plan Enclosed ___ (TC Permit will not be processed without a TCP plan)

If no, describe why:

Approval is conditioned on the following terms that are deemed accepted by the Contractor upon submission of this Permit

1. Traffic Control for operations under this permit shall conform with the Manual on Uniform Traffic Control Devices (MUTCD).

2. The Contractor agrees to indemnify and hold harmless the NMDOT and its employees from liability, claims, damages losses or expenses due to any negligent act of the Contractor, the Contractor’s employees, any agent acting on the Contractor’s behalf, and anyone else engaged by the Contractor to work pursuant to this permit.

3. The Contractor shall provide the NMDOT a certified copy of the its insurance policy and certificate of insurance and shall include on the certificate of insurance the NMDOT as an additional-named insured, with notice that the coverage is primary over any other valid insurance.

4. Any additional conditions as attached and referenced below.

For Official Use:

Approved (see conditions below) Approved As Amended Not Approved

Contractor/TCP firm SHALL contact the District Office and confirm the actual start dates.

TCP Firm and Contractor must adhere to the attached notes.

Permit Number: - Approved By

NMDOT District Office – Traffic Section Submitted to the District Public Information Officer By:_____________________________ On:____/_____/_____