Tr0100 Form – Fill Out and Use This PDF

8. WORK TO BE PERFORMED BY

9. ESTIMATED START DATE

10. ESTIMATED COMPLETION DATE

OWN FORCES

CONTRACTOR

11.

MAX. DEPTH

AVG. DEPTH

AVG. WIDTH

LENGTH

SURFACE TYPE

EXCAVATION

12.

ESTIMATED COST WITHIN STATE HIGHWAY RIGHT-OF-WAY

FUNDING SOURCE(S)

FEDERAL

STATE

LOCAL

PRIVATE

13.

PRODUCT TYPE

DIAMETER

VOLTAGE / PSIG

14. CALTRANS' PROJECT CODE (ID)

PIPES

15.

Double Permit

Parent Permit Number

____________________________________________________

Applicant's Reference Number / Utility Work Order Number

_______________________________________

16.

Have your plans been reviewed by another Caltrans branch?

NO

YES (If "YES") Who? ______________________________________

17.

Completely describe work to be done within STATE Highway right-of-way:

Attach 6 complete sets of plans (folded to 8.5" x 11") and any applicable speciications, calculations, maps, etc.

18. Is a City, County or other public agency involved in the approval of this project?

YES (If "YES", check type of project AND attach environmental documentation and conditions of approval)

COMMERCIAL DEVELOPMENT	BUILDING	GRADING	OTHER _____________________________________________________________________
CATEGORICALLY EXEMPT	NEGATIVE DECLARATION		ENVIRONMENTAL IMPACT REPORT	OTHER ____________________________________

NO (If "NO", please check the category below which best describes the project AND answer questions A - K on page 2)

DRIVEWAY OR ROAD APPROACH, RECONSTRUCTION, MAINTENANCE OR RESURFACING

PUBLIC UTILITY MODIFICATIONS, EXTENSIONS, HOOKUPS

FLAGS, SIGNS, BANNERS, DECORATIONS, PARADES AND CELEBRATIONS

OTHER _____________________________________________________________________________

ADA NOTICE: For individuals with sensory disabilities, this document is available in alternate formats. For information, call (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.

The following questions must be completed when a City, County or other public agency IS NOT involved in the approval of this project.

Your answers to these questions will assist Departmental staff in identifying any physical, biological, social or economic resources that may be affected by your proposed project within State Highway right-of-way and to determine which type of environmental studies may be required to approve your application for an encroachment permit.

It is the applicant's responsibility for the production of all required environmental documentation and supporting studies and in some cases this may be costly and time

consuming. If possible, attach photographs of the location of the proposed project. Please answer these questions to the best of your ability. Provide a description of any "YES" answers (type, name, number, etc.)

A. Will any existing vegetation and/or landscaping within State Highway right-of-way be disturbed?

__________________________________________________________________________________________________________________________________________________

B. Are there waterways (e.g. river, creek, pond, natural pool or dry streambed) adjacent to or within the limits of the project or State Highway right-of-way?

__________________________________________________________________________________________________________________________________________________

C. Is the proposed project located within ive miles of the coast line?

__________________________________________________________________________________________________________________________________________________

D. Will the proposed project generate construction noise levels greater than 86 dBA (e.g. jack-hammering, pile driving)?

__________________________________________________________________________________________________________________________________________________

E. Will the proposed project incorporate land from a public park, recreation area or wildlife refuge open to the public?

__________________________________________________________________________________________________________________________________________________

F.Are there any recreational trails or paths within the limits of the proposed project or State Highway right-of-way?

__________________________________________________________________________________________________________________________________________________

G.Will the proposed project impact any structures, buildings, rail lines or bridges within State Highway right-of-way?

__________________________________________________________________________________________________________________________________________________

H.Will the proposed project impact access to any businesses or residences?

__________________________________________________________________________________________________________________________________________________

I.Will the proposed project impact any existing public utilities or public services?

__________________________________________________________________________________________________________________________________________________

J.Will the proposed project impact existing pedestrian facilities, such as sidewalks, crosswalks or overcrossings?

__________________________________________________________________________________________________________________________________________________

K.Will new lighting be constructed within or adjacent to State Highway right-of-way?

________________________________________________________________________________________________________________________________________________

19. Will this project cause a substantial change in the signiicance of a historical resource (45 years or older), or cultural resource?		YES		NO
(If "YES", provide a description)

20.Is this project on an existing State Highway or street where the activity involves removal of a scenic resource including a signiicant tree or stand of trees, a

rock outcropping or a historic building?

YES

NO (If "YES", provide a description)

21.Is work being done on the applicant's property?

					YES		NO	(If "YES", attach 6 complete sets of site and grading plans.)
22.	Will the proposed project require the disturbance of soil?								YES	NO
	If "YES", estimate the area within State Highway right-of-way in square feet AND acres: _____________________ (ft2) AND ______________________ (acres)
	estimate the area outside of State Highway right-of-way in square feet AND acres: ______________________ (ft2) AND _____________________ (acres)
23.	Will the proposed project require dewatering?							YES	NO
	If "YES", estimate total gallons AND gallons/month. __________________________ (gallons) AND __________________________ (gallons/month)
	SOURCE*:	STORM WATER	NON-STORM WATER
	(*See Caltrans SWMP for deinitions of non-storm water discharge: http://www.dot.ca.gov/hq/env/stormwater/index.htm )

24.How will any storm water or ground water be disposed of from within or near the limits of the proposed project?

Storm Drain System

Combined Sewer / Storm System

Storm Water Retention Basin

Other (explain): _____________________________________________________________________________________________________________________

PLEASE READ THE FOLLOWING CLAUSES PRIOR TO SIGNING THIS ENCROACHMENT PERMIT APPLICATION.

The applicant, understands and herein agrees that an encroachment permit can be denied, and/or a bond required for non-payment of prior or present encroachment permit fees. Encroachment Permit fees may still be due when an application is withdrawn or denied, and that a denial may be appealed, in accordance with the California Streets and Highways Code, Section 671.5. All work shall be done in accordance with the California Department of Transportation's (Department) rules and regulations subject to inspection and approval.

The applicant, understands and herein agrees to the general provisions, special provisions and conditions of the encroachment permit, and to indemnify and hold harmless the State, its oficers, directors, agents, employees and each of them (Indemnitees) from and against any and all

claims, demands, causes of action, damages, costs, expenses, actual attorneys’ fees, judgments, losses and liabilities of every kind and nature whatsoever (Claims) arising out of or in connection with the issuance and/or use of this encroachment permit and the placement and subse-

quent operation and maintenance of said encroachment for: 1) bodily injury and/or death to persons including but not limited to the Applicant, the State and its oficers, directors, agents and employees, the Indemnities, and the public; and 2) damage to property of anyone. Except as provided by law, the indemniication provisions stated above shall apply regardless of the existence or degree of fault of Indemnities. The Ap-

plicant, however, shall not be obligated to indemnify Indemnities for Claims arising from the sole negligence and willful misconduct of State, its oficers, directors, agents or employees.

An encroachment permit is not a property right and does not transfer with the property to a new owner.

COMPLIANCE WITH THE AMERICANS WITH DISABILITIES ACT (ADA) OF 1990: All work within State Highway right-of-way shall be conducted in

compliance with all applicable Federal, State and Local Access laws, regulations and guidelines including but not limited to the Americans with

Disabilities Act Accessibility Guidelines (ADAAG), the Public Rights-of-Way Guidelines (PROWG), the Department’s current Design Information

Bulletin82,“PedestrianAccessibilityGuidelinesforHighwayProjects”,theDepartment’sEncroachmentPermitsManualandencroachmentpermit.

DISCHARGES OF STORM WATER AND NON-STORM WATER: All work within State Highway right-of-way shall be conducted in compliance with

all applicable requirements of the National Pollutant Discharge Elimination System (NPDES) permit issued to the Department, to govern the

discharge of storm water and non-storm water from its properties. Work shall also be in compliance with all other applicable Federal, State and

Local laws and regulations, and with the Department’s Encroachment Permits Manual and encroachment permit. Compliance with the Depart-

ment's NPDES permit requires amongst other things, the preparation and submission of a Storm Water Pollution Protection Plan (SWPPP),

or a Water Pollution Control Program (WPCP), and the approval of same by the appropriate reviewing authority prior to the start of any work.

Information on the requirements may also be reviewed on the Department's Construction Website at:

http://www.dot.ca.gov/hq/construc/stormwater

25. NAME OF APPLICANT OR ORGANIZATION

ADDRESS OF APPLICANT OR ORGANIZATION WHERE PERMIT IS TO BE MAILED (Include City and Zip Code)

E-MAIL ADDRESS				PHONE NUMBER			FAX NUMBER
26. NAME OF AUTHORIZED AGENT / ENGINEER (A "Letter of authorization" is required if different from #25)						IS A LETTER OF AUTHORIZATION ATTACHED?
							YES	NO
	ADDRESS OF AUTHORIZED AGENT / ENGINEER (Include City and Zip Code)
E-MAIL ADDRESS				PHONE NUMBER			FAX NUMBER
27. NAME OF BILLING CONTACT (Same as #25		Same as #26 )
BILLING ADDRESS WHERE INVOICE(S) IS/ARE TO BE MAILED (Include City and Zip Code)
E-MAIL ADDRESS				PHONE NUMBER			FAX NUMBER
28. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT			29. PRINT OR TYPE NAME		30.TITLE			31. DATE