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REQUIRED ITEMS FOR SUBMITTAL: 1. Permit Application 2. Copy of your CDPHE Storm Water Permit if applicable. 3. Site plan outlining the area affects and details of the proposed improvements. 4. Project area must be staked out for initial review before permit will be issued. 5. Traffic Control Plan. 1. Copy of the final approved permit must be on the job sit at all times. 2. 3. 4. 5. 6. 7. Owner's Signature Contractor Signature Date Date Permit Approval □ Yes □ No Signature Date Stake Approval □ Yes □ No Signature Date Final Inspection Signature Date ~ OVER ~ ELBERT COUNTY APPROVAL Proposed Improvement: Owner Email: Elbert County shall be provided unrestricted access to the site to conduct regular site inspections. Immediately cease land-disturbing activities upon receipt of a written Stop Work Order from an authorized representative of Elbert County. If a Stop Work Order is issued, this permit will be revoked if the applicants are not in compliance with the Elbert County Grading Permit and Construction Standards and Specifications Manuel or if the applicants fail to take corrective action within the time specified on the written notification of such non- compliance. Project Address: Subdivision: Use proper erosion control methods and materials. All improvements must conform to the requirements set out in the Elbert County Construction Standards and Specifications Manual, all state requirements regulating construction and with the M.U.T.C.D. RIGHT-OF-WAY PUBLIC/PRIVATE IMPROVEMENT PERMIT Permit Elbert County Public Works Department Date P.O. Box 116, 215 Cheyenne St., Kiowa, CO 80117 Ph: [PHONE REDACTED], Fax: [PHONE REDACTED] Revision Date: 1/9/19 Permit Applications may be emailed to: [EMAIL REDACTED] Property Owner: Contractor Name: Owner Address: Contractor Address: City/State/Zip I certify that I have read and understand all of the above provisions of this permit. IMPORTANT INFORMATION FOR THE APPLICANT City/State/Zip Owner Phone: Contractor Phone: Contractor Email: No open holes shall be left in the ROW overnight. No stockpiling in ROW. ---PAGE BREAK--- FEE SUB-TOTAL $60 EA $0.19 LF $0.27 LF $0.44 LF $0.77 LF $0.97 LF $5.00 SF $2.00 SF $130.00 EA $75.00 EA $5.00 SF $5.00 EA $85.00 EA $0.11 SY $0.11 SY $0.11 SY $55 EA $28 EA $55 $0.10 LF $0.11 LF $0.10 LF $45 $45 $53 $0.11 LF $0.17 LF $60 Base Fee Only $0.90 LF $75 EA $150 EA $60 $0.10 SY $0.11 SF (face) $50/basin $0.09 SY $60 $0.20 CY $0.15 TN $0.09 SY $50 EA $50 EA $75 EA $37 EA $53 EA $500 EA $500 EA $12.50 EA $75 EA $200 $200.00 $600 $ BASE FEE PIPE CULVERT OR PRECAST BOX: VALLEY PAN OR TRICKLE CHANNEL (Detention Ponds or Drainage Ways) BASE FEE PUBLIC-PRIVATE IMPROVEMENT/RIGHT-OF-WAY PERMIT CATEGORIES Handicap Ramp BASE FEE CAST-IN-PLACE STORM SEWER VAULTS/INLETS OR JUNCTION BOXES LANDSCAPE/RETAINING WALLS Curb & gutter without sidewalk Sidewalk with integral curb & gutter > 10 sqare yards CROSS-PANS First Cross Pan Additional Cross Pans Landscape Plus Square Yards 6' or smaller BASE FEE: (Circle all that apply) Subgrade/Base Course/ Surface Surface Porous Landscape/Sand Filters Per Basin Retaining Walls > 4 ft in height BASE FEE Bore Pit Pot Hole STREET/ROAD CONSTRUCTION CONSTRUCTION STREET CUT Paved Road Pipe/Cable 43" and larger QUANTITY DESCRIPTION BASE FEE: TO/SAN/WAT/PHO/FO/ TRENCH/ TV/GAS/ELEC/CONDUIT Pipe/Cable 0.5" - 8" Pipe/Cable 8.25" - 16" Pipe/Cable 16.25" - 24" Pipe/Cable 25" - 42" RIP-RAP EROSION PROTECTION BASE FEE Rip-Rap Plus Cubic Yard Rip-Rap Plus Tonnage Fore Bay Micro Pool Manhole (San/Storm) Traffic Sign Bridge/Cast-in-place Box Culvert Vehicle Tracking Control Pad Vehicle Tracking Control with Wheel Wash MISCELLANEOUS Vehicle Tracking Control with Wheel Wash ADMINISTRATVE Utility Handhole/Pull Box Larger than 6' Traffic Signal (per location) Valley Pan Concrete Trickle Channel Administrative/Inspection Fee 1 36" or smaller Greater than 36" Boring/Jacking/Tunneling TOTAL FEES Sidewalk without curb & gutter Sidewalk Chase Drain SIDEWALK/CURB & GUTTER/HANDICAP RAMP Reinstatment Fee (Stop Work Order Issued) Subgrade Base Course Gravel GESC Compliance