application for permit to construct an access or median opening on ...

F<strong>or</strong>m No. A-64
New 11/12
APPLICATION FOR PERMIT TO CONSTRUCT AN ACCESS OR MEDIAN OPENING ON
PUBLIC RIGHT-OF-WAY
Department Use Only
District No._________ Permit No._______________ State Highway No._______
Project No._________ Station No.(s)____________ Mile Post(s)_____________
Posted Speed_______ Highway ADT____________ Sight Dist<strong>an</strong>ce___________
Type of Vehicle___________________________ Estimated Driveway ADT______________
TO: NEW MEXICO DEPARTMENT OF TRANSPORTATION
ATTN: DISTRICT ENGINEER
( ) Deming ( ) Roswell ( ) Albuquerque ( ) Las Vegas ( ) S<strong>an</strong>ta Fe ( ) Mil<strong>an</strong>
Application is hereby made by_____________________________, _____________________________
(Owner of Property) (Mailing Address)
_________________________, <strong>to</strong> develop <strong>or</strong> redevelop a __________________________ with the
(Type of Development)
estimated driveway ADT as listed above, <strong>f<strong>or</strong></strong> permission <strong>to</strong> <strong>construct</strong> ( ) <strong>access</strong>(es), <strong>or</strong> ( ) medi<strong>an</strong>
<strong>opening</strong>(s) <strong>or</strong> <strong>to</strong> ( ) modify <strong>or</strong> tr<strong>an</strong>sfer <strong>an</strong> existing lawful <strong>access</strong> <strong>permit</strong>, <strong>an</strong>d/<strong>or</strong> ( ) <strong>to</strong> upgrade <strong>an</strong> existing
illegal <strong>access</strong> <strong>to</strong> a lawful <strong>access</strong> at the following described location:
____________________________________________________________________________
____________________________________________________________________________
in ________________County, on State Highway___________ in acc<strong>or</strong>d<strong>an</strong>ce with the attached pl<strong>an</strong> <strong>or</strong>
sketch. W<strong>or</strong>k will commence on <strong>or</strong> about ___________ <strong>an</strong>d will require approximately ______days.
(month, day, year)
The proposed driveway <strong>or</strong> medi<strong>an</strong> <strong>opening</strong> must be located, designed <strong>an</strong>d <strong>construct</strong>ed in acc<strong>or</strong>d<strong>an</strong>ce with 18.31.3
NMAC, State Highway Access M<strong>an</strong>agement Requirements. A Gate ( ), Cattle Guard ( ), Additional Fence ( ),
Drainage Structure ( ), will be required which owner agrees <strong>to</strong> furnish <strong>an</strong>d hereafter maintain in good repair <strong>an</strong>d
closed <strong>to</strong> lives<strong>to</strong>ck. The applic<strong>an</strong>t shall submit a <strong>construct</strong>ion traffic control pl<strong>an</strong> <strong>f<strong>or</strong></strong> approval. The owner will protect,
indemnify, <strong>an</strong>d hold the New Mexico Department of Tr<strong>an</strong>sp<strong>or</strong>tation harmless from <strong>an</strong>y injury <strong>or</strong> damage caused the
owner, <strong>or</strong> third parties, by owner’s failure <strong>to</strong> comply with the above. If this <strong>permit</strong> is gr<strong>an</strong>ted, owner further agrees <strong>to</strong>
comply with all condition, restrictions, <strong>an</strong>d regulations of the New Mexico Department of Tr<strong>an</strong>sp<strong>or</strong>tation. If not
<strong>construct</strong>ed, this <strong>permit</strong> will expire six (6) months from the date of issue unless otherwise noted <strong>an</strong>d approved. The
<strong>permit</strong>tee shall notify the District Engineer of the pending <strong>construct</strong>ion at least three (3) w<strong>or</strong>king days pri<strong>or</strong> <strong>to</strong> <strong>an</strong>y
<strong>construct</strong>ion, <strong>an</strong>d upon completion, which shall be within 45 days of initiation of <strong>construct</strong>ion. The <strong>permit</strong>tee, his <strong>or</strong> her
heirs, success<strong>or</strong>s-in-interest, assigns, <strong>an</strong>d occup<strong>an</strong>ts of the property serviced by the <strong>access</strong> shall be responsible <strong>f<strong>or</strong></strong>
the repair <strong>an</strong>d mainten<strong>an</strong>ce of the <strong>access</strong> beyond the dge of the roadway including <strong>an</strong>y cattle guard <strong>an</strong>d gate, <strong>an</strong>d
the removal of snow <strong>or</strong> ice upon the <strong>access</strong> even though deposited on the <strong>access</strong> in the course of the Department
snow removal operations. Any w<strong>or</strong>k in state highway right-of-way must be approved in writing by the Department
pri<strong>or</strong> <strong>to</strong> initiating the w<strong>or</strong>k.
Place (Of Notary)_________________________ ___________________________________
(Owner’s Signature)
Sw<strong>or</strong>n <strong>to</strong> <strong>an</strong>d subscribed be<strong>f<strong>or</strong></strong>e me this _______ By ________________________________
Day of _______________________, 20_______ Title _______________________________
My commission expires ____________________ Owner’s Phone No. ___________________
(Notary Public)
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F<strong>or</strong>m No. A-64
New 11/12
Department Use Only
Permission gr<strong>an</strong>ted this _____________day of ____________________________, 20____, subject <strong>to</strong> the above stated conditions
<strong>an</strong>d the following additional requirements (attach separate sheet as required:)
____________________________________________________________________________________
Deviation from the stated conditions <strong>or</strong> the approved sketch may be grounds <strong>f<strong>or</strong></strong> revocation.
Distribution: NEW MEXICO DEPARTMENT OF TRANSPORTATION
Original: G.O. Files
Copies: District Engineer By_____________________________________________
Applic<strong>an</strong>t (District Engineer <strong>or</strong> Designee)
Traffic Services Engineer Title_____________________________________________
NAME:
ADDRESS:
ACCESS INFORMATION
CITY: STATE: ZIP:
COUNTY: PHONE:
1. ROUTE No. (S.R./US): State Road
2. LOCATION (NEAREST MILEPOST) Mile Post
3. ACCESS WIDTH:
4. LENGTH OF PROPERTY FRONTAGE:
5. ACCESS TYPE (commercial/residential/other):
6. ACCESS RADIUS:
7. GATE/CATTLE GUARD/OTHER:
8. TYPE OF SURFACE MATERIAL:
1. POSTED SPEED:
2. SIGHT DISTANCE:
3. DRAINAGE:
4. CULVERT SIZE:
5. CONC. END BLANKETS:
6. R.O.W. TO R.O.W. WIDTH:
*****FOR OFFICIAL USE ONLY*****
7. DRIVING LANE WIDTH: SHOULDER WIDTH:
8. HIGHWAY A.D.T.: ESTIMATED ACCESS A.D.T.:
SPECIAL NOTES AND/OR CONDITIONS
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