HomeMy WebLinkAboutCorrespondence ODOT 5/19/2009
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Application for State Highway Appro~ch
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Pre-application Meeting Requirements: Ii
Applications submitted for the purpose of a pre-application meeting, must contain all of the
following items: '
o Application: Pages 1 - 3 completed.i!
o Application: Page 2: (Authorization of Designated Agent.) Ii
If the applicant is not the owner of the property, where-as the app~oach is
connecting to and serving, then the property<owner must complete the Authorization
of Designated Agent section or submit a sign~d letter from the property owner
authorizing the applicant as the designated agent for this applicati,pn.
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o Application Site Plan: (Page 3 of application.) . '
The site plan is to.be specific to the approach being applied for. .A:ILavailable and
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pertinent items bulleted on..page 3 are to be included. I'
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o Local Government Site Plan (Page 3 of application.) :
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If the local government is reviewing a site plan or has approved a :site plan, attach a
copy of the plan(s).
o Land Use Application.
Is the property currently or recently going through local land use r~view? If yes,
provide a copy of the land use application or decision from the 10c~1 government.
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o Tax Lot Map. I'
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A cop of the current County tax lot map for the property served bY:ithe approach.
Map must highlight all properties that would be served by the app~oach.
Identify the ownership of all adjacent properties on the map.
Identify the location of the proposed approach location on the maJ.
o Recorded Easements. .
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Provide a copy of the recorded easements for access to the property.
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Application Submittal Requirements:
Applications submitted for the purpose of applying for an approach, must contain all of the
following items: \ I'
o All Pre-Application items listed above.
o Application: Page 4 (Land Use Compatibility Statement, LUCS)
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Must be completed prior to submitting the application to ODOT. Section 1, can be
____completedJiy,ttle:appIi6abt' or the local jurisdiction. Section 2, mu~t be completed
by the local jurisdictior,~[;h Dat~ Received' S...1l9 \ 00. ) ~ _. '-
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Pre~Application Meeting for
State Highway Approach
Review
Pre-application Meeting:
Is the intent of submitting the approach application and materials for a pre-application
meeting? .
~ No. I am submitting the application for processing. ..
o Yes. I am only submitting this application for the purpose of a pre-application.
. meeting. The submittal of the application and associated materials are intended for
the sole purpose of meeting with ODOT to review the' site and access. This
apPli~.. n~t~o be processed for erm~g, at this time.
1 Signe'a;. I.{' ^ U ) U- . ~ '. . Date: 0>//9/01
.1 Name (pnnied} p \ \ \ \ () A Co. 'P-Lll.\-tIJ b
1 Office PhoneSlf/7l/I..A D 'SS Cell Phone: '11 2. ~/ IJCj / Fax:
MailingAddress:37Jzy J--f.r))) rY-"'t IC~
City: c::a f ~ I \) State: ~ Zip Code:17 V '/ P
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If you have any questions or comments, please contact your local permits .office at:
ODOT, District 5
644 'A' Street
Springfield, OR 97477
(541) 744-8080
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Date ReceiVed;~1 oCl . O'
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Oregon Department of Transportation
Application for State Highway::Approach
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Required Information '. . I' .
The applicant must submit the following information with the Application for State Highway Approach. OOOT will noiify
the applicant if additional information is required. Ii
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. All attachments required by answers on the application form, including applicant signature.
. If the applicant is not the owner of the property to be served by the approach, then the property owner must authoriz~l;
the applicant as a designated agent. The applicant must have the property owner complete the Authorization of
Designated Agent block on this form OR submit a signed letter from the property owner a~thorizing the applicant as
the designated agent. :'
. Site plan and vicinity map approved Of currently being reviewed by the local government
. A Land Use Coinpatibility Statement (LUCS) far a State Highway Approach (page 4 of this application) must be
completed by the local government.
. A copy of the current County tax lot map for the property served by the approach. Map must highlight all property that
would be served by the approach and list all owner name(s) on adjacent properties. Make a note on map if ownership
of adjacent property is same as subject property. Identify the location of the proposed approach on map.
. A copy of the recorded easement(s). if the subject property has an existing easement(s) f~r access to the property.
. A copy of any existing state or local government approach permits for the property. ,
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In addition to the above submittals, the applicant may be required to place stakes or markings!:near the highway shoulder'
at the proposed approach location.' :;
Definitions for commonly used tefms are in the attached brochure. The brochure is also available on the OOOT web site
located at: htto:l/www.oreoon.oov/OOOT/HWY/ACCESSMGT/ ii
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I Applicant Information
I Last Name~ff' L Pi Iv f) . .
I Street Address. 37/2- y\ }/ J~/ / '\
ICity~pr- ^-J~ .
I Mailing Aadress Of).s~
I City: I State:
I Phone Number: 5'11 - 7 (/ L. -Cj 01 c;:
I Cell Phone Number: 5 l/ 1 ~ ~ I /_' -) lj y (
I E-mail Address:
Is applicant working as an Agent of the Owner? YES: D NO: 9 i:
If YES. the owner must complete the Authorization of Designated Agent section below, OR AtTACH a letter from the
, owner authorizing applicant to act as his/her agent.
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I First Nam}1 ; I \ f () '<1 \ )Il" ..,.,J c(m1>~~.l ^N f) ~ 2.-
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I Sta~ I ZiPCOdej7V7X- I ~ounty L.~
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I County:
Zip Code:
FAX.Number:
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Approach Location' ..' . I'
Highway Name _ May be a statewide highway name such as Pacific Highway, or a local name like East Main Street.
Route Number - The posted highway number, e.g. 1-5 or US-84 I!
Highway Name~1I PA",.;-L It '" ~ Route Number: 12./0 County: L;CJ/),!!F
Mile Point:. ~^ sicle of High.:vay:' N~rth!Xl . South 0 East 0 West 0
.Is the highway!in a nation~~f.9~estarea?:. Yes 0 No .K.J
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734-2680 (8108)
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my agent in the matter of this highway approach permit application.
I Owner Signature: I Date:
LAPlllicant Signature' '. ' ."" ..;.' ':{.'-.!('
NOTIFICATION TO APPLICANT: The ODOT District Office will contact you when your application has been reviewed. If additional
documents are required to continue the application process you will be notified. When all of the necessary documents have been
received, the application will be deemed complete. If your completed application is approved, preliminary construction specifications
will be issued. A performance bond and liability insurance will be required before any construction work can begin on the highway right
of way. For the complete rules regarding approach permitting, see OAR Chapter 734 Division '51. .
The Applicant declares, certifies, and affirms under penalty of applicable state or federal laws that all information
provided on this form and atta~h~ents are true and co~o the best. of hi:!!:er k~. wlleecdge. . '. " '. .
I:;:~:i::::f~~r~~~hr,ne~~~:: (ANd I. s'~natt~ .'0S~~1 D:te(s7ifi~fl'
Application is a request for (check all that apply)'
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o New Approach - There is no existing permitted or grandfathered approach road at the location requested in this
application '
o Temporary Approach - The approach requested will be removed after a specified period of time
~ Existing Approach - This application affects, or may affect, an existing approach
o Restricted Use Approach - The approach requested is for emergency services. government, utility access or similar
specific uses with limited traffic
I Vehicle Turninq Movements ". "
Turn movements requested (check all that apply)
All movements:16 OR Right In: 0 Right Out: 0 Left In: 0 Left Out: 0
Property Owner Information (If different than appiicant)
I Last Name: ~ 1 First Name:
Street AddreSSj' ~ 1:1 -r
City .' ~ \--*,.i~ I CL.Jtstate: I Zip Code:
Mailing Address:' - . er-
City: I State
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Current zoning: ~~ Proposed zoning: I
In the boxes below, describe the existing and proposed land use(s) on the property. including square footage or acreage. I
Eji;i:go 51 i/ ~~ BU\\~'Jft Proposed: 5~I'ied: ^~;~~~~~
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I Authorization of Designated Agent
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(printed name of property owner) authorize
(orinted name of applicant) to represent me as ,
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I County:
Phone Number:
I Zip Code:
FAX Number:
I County:
Cell Phone Number:
E-mail Address:
Are there additional owners of the subject property? YES: 0 NO: i?1i
If YES, ATTACH the same contact information as above for each of the co-owners on a separate shee.t of paper.
Property Information (attach additional page(s) if space is insufficient)
Subjectpropertyaddres~s): :s9/2....' ~~ Stv'
Cit:C::PO_""') ~ / CS1-Z--- I Zip Code 97'17[5
ToWnS~iP(~)Y~(.D !'Range(S) Section(s)
I '1-oJ. -:3 /-'-/ /
I County: Lc:vvJl-
I Tax lot(s)
/411 /
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'Has the local government approved a ~ite plan or is the local government currently relieWing a plan for the
proposed land use? :'
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Yes (If yes, attach a copy of the plans being reviewed by the local government.)"
No ,,' .'. ':':
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Submit drawing(s) no larger than 11" x 17" in size.
below: '
Site plants) shall include all apPlid~ble information listed
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Property location and property lines, including:
. North arrow
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. Show all lots or parcels that are part of the property or development with their ~orresponding tax lot
numbers identified .
. Distance from the property lines to the center of the proposed approach
Using solid lines, show:
. Proposed approaches with requested width and turning movements shown
. Proposed & existing buildings and structures to be retained
. Proposed use of existing buildings and structures to be retained.
. Other proposed equipment or facilities and their proposed use I,.
. Proposed access or "cross-over" easements with neighboring properties I,
. Nearest approaches on both sides of the highway within 500' of the proposed 'approach center-line
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Using dashed lines, show:
. Existing approaches with width and turning movements shown
. Place an "X" on approaches to be removed
. Existing buildings .and structures to be removed
. Existing equipment or facilities to be removed
. Other existing facilities to be removed
. Existing access or "cross-over" easements with neighboring properties
Show proposed on-site circulation, including:
. Travel lanes with travel directions indicated
. Travel lane widths
. Parking spaces or parking areas
. Access locations to the parking spaces or areas
Show nearest landmark or cross street:
. Provide nearest cross street name
. Distance from the requested approach location to the nearest cross street
. All public streets that abut the property(s)
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Oregon Department of Transportation
Land Use Compatibility Statement (LUCS)
What is a LUCS? A Land Use Compatibility Statement (LUCS) is the form ODOT uses to ensure that Highway Approach Permits are
consistent with loca[ land use requirements. .
Why is a LUCS Required? ODOT Coordination Rules, OAR 731-015. identify Highway Approach Permits as permits that affect [and
use. State law requires ODOT activities that affect [and use to be consistent with acknowledged local comprehensive p[ans...
When is a LUCS Required? An ODOT LUCS must be submitted with every ODOT Highway Approach Permit Application.
How to Complete the LUCS: The applicant completes Section 1. Section 2 must be completed by the [ocal jurisdictio~. The
applicant then submits the completed LUCS to ODOT as part of the Highway Approach Permit App[ication. .
I SECTION 1: Applicant & Site Information . ,
I Print applicant name: I Applicant signature:
I Property owner name:
I Subject property address:
I Site description:
Describe the proposed activity, use. or development, including type and volume of traffic it will generate.
Township(s)
Range(s)
Section(s)
Tax [ot(s)
SECTION 2 must be filled out by a Local Planning Official
SECTION 2: Determination of Compliance with Local Land Use Requirements
The subject property is: 116 Inside D Outside City Limits' D Inside D Outside UGB ~" , OJ
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Current Comprehensive Plan designation:_ ./ Current zoning: ~ ^----' . " QVY'\YY\l.LfI, \ (f- lJ}'f1'''V
[s a Comprehensive Plan or zoning amendment proposed? YES D NO 5?" U
[f YES, list the proposed plan designation: proposed zoning:
Does the activity, use, or development require [and use review to determine compliance with [and use regU[ation~? YES ~ NO D
If NO, it means that no local land use review is needed. Skip to Local Planning Official Information below.
If YES, what is the status of the land use application: JSi Approved tJ Denied D Under review D Not yet received
List file nUmber(S)~ t( ~ }rr)q -f(Y)1 0 ' Is the decision. final:' YES' ~ NO D
Comments Hfflfh'Vlfl W~CtWJ,hOA-\
I Local Planning Officiallnfol1!1ation (Required):
I Jurisdiction CrtLt-- 6 f,. ~O(I V1(}li e!vl
I Print planning officiaOs name\;lnd tit[~ V D 1-1 '2.. Ynil1fl
I Mai[ing Address iflS S 1k So h-e .tl- I
I City <::: /1 j')~~krtlo" Zip Code '1 J 1fT I
IPhone rLS4f)V illrl101 Fax LS4111;)(n-~&~1
Emai[ 1- 1 Mdt VbJ..~L 'S,1?;1~Ai(.,.jti... f)r us..
Planning Official's Signature: L1\~A.'{ Al1 VI1/\-.
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