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For County Use Only Planning Department Confirmation of Current Zone District: Print Full Name PARK COUNTY APPLICATION FOR GRANT OF LICENSE WITHIN A PUBLIC RIGHT-OF-WAY NON-REFUNDABLE APPLICATION FEE: $700 All applicants must submit one complete application and attend a pre-application conference with the Park County Planning Department Staff seven to ten (10) working days prior to the application submittal deadline. Following the acceptance of the complete application the applicant must submit one paper copy of the application and eight copies of the preliminary Survey Plat to the Park County Planning Department on or before the application submittal date. If you have questions regarding this form please contact the Planning Department by phone at (719) 836-4292, or e-mail [EMAIL REDACTED], fax (719) 836-4351, or write to us at P.O. Box 1598 Fairplay, CO 80440. A. APPLICANT AND OWNERSHIP INFORMATION Applicant’s Name: Mailing Address: City: Telephone Owner’s Mailing Telephone No. and Email B. PROPERTY INFORMATION Complete Legal Description of Property Proposed for the Grant of License in a Public Right-of Way (attach additional page, if necessary): Street Address of Property: Property’s Total Acreage: Current Zone District of Property: ---PAGE BREAK--- Page 2 of 10 Grant of Easement within R.O.W. – Revised October 2025 Requirements for a Grant of License within a Public Right-of-Way Article VI, Division 12, Section 6-1202 C. APPLICATION REQUIREMENTS 1. Application Fee. An application fee in the amount of $700 must be paid at the time of submission of the application. Make the check or money order to: Park County Planning Department. The fee pays for the typical cost to the County to process the application. Any additional costs that may occur are the applicant’s responsibility. 2. Tax receipt showing payment of current taxes. This can be obtained at the Park County Treasurer’s office. 3. Proof of ownership in the form of a recorded Warranty Deed. This can be obtained at the Park County Clerk and Recorder’s office. 4. A list of names and mailing addresses of all owners of adjacent property to the property subject to the proposed plat amendment, this information is at the Park County Assessor’s Office 5. Certified Land Survey Plat for the property subject to Grant of License within a Public Right-of-Way The Grant of License plat shall be drawn, signed and stamped by a currently registered Colorado land Surveyor at a commonly used engineering scale. The size of the map sheet shall be twenty-four by thirty-six inches (24” x 36”). At a minimum, the Grant of License plat shall show or illustrate: a. A title with the phrase “Grant of License within a Public Right-of-Way Plat”; and, b. Date of preparation, map scale, and north arrow; and, c. Name, address and telephone number of the surveyor; and, d. A general vicinity map illustrating the location of the lot proposed to be served by the Grant of License including the owners name; and, e. A graphic depiction of the lot to be served by the license with a clear indication of the license area itself, including a written legal description of the license area with the total acreage. The survey must contain all structures and infrastructure on the lot to be served by the license and include all existing easements and the affected right-of-way; and, f. Primary boundary survey control points with monument descriptions; all parcel lines dimensioned with curve data including chord and bearings; basis of bearings and relation to true meridian. All required boundary monuments shall be placed in the field before the Grant of License is recorded; and, g. Name and right-of-way width of each street or road subject to the Grant of License. Right-of-way widths are to be shown at each leg of an intersection, at point of curvature and point of tangency, at dead-ends, and at angle points; and, h. Approval certification and plat language Forms A-2, A-3 and A-4, as identified in Appendix A (attached) of the Land Use Regulations. The Board of County For County Use Only: Initial Receipt of the Required Information ---PAGE BREAK--- Page 3 of 10 Grant of Easement within R.O.W. – Revised October 2025 Commissioners may modify the form of certification upon the advice of the County Attorney; and, i. Location of existing utilities within or adjacent to the area proposed for the Grant of License, including water, sewer, electricity, gas and phone lines. 6. The property must be clearly identified with the address and posted according to the Park County address requirements (attached). 7. Written description of the reason for the Grant of License explaining why it is necessary to avoided extreme practical difficulty in the use of the lot and of how the Grant of License will not substantially impede the use of the right-of-way by the public. 8. A $43.00 check made out to the Park County Clerk and Recorder to record the plat. Note: Refer to Park County Land Use Regulations Article VI Standards for Approval. Note: A Mylar as described in #5 will be required after final approval for recording. For County Use Only: Initial Receipt of the Required Information ---PAGE BREAK--- Page 4 of 10 Grant of Easement within R.O.W. – Revised October 2025 D. APPLICANT AND LANDOWNER SIGNATURES: The undersigned applicant and landowner hereby verifies and affirms that the information contained in this application is complete and accurate. The undersigned applicant and landowner understands and acknowledges that the submission of inaccurate and incorrect information may result in the denial or rejection of the application and/or result in the invalidation of any approvals issued by Park County, Colorado. Applicant: Signed: Print name: If company, state Title/Position: E. VERIFICATION OF DATE OF DELIVERY OF APPLICATION This application was submitted to the Park County Planning Department on the following date and time: Month Day Year Payment of the Applicant Fee was made by: Personal Check Amount $ Cash Amount $ Amount $ APPLICANT MUST ATTEND THE HEARING. IF A REPRESENTATIVE ATTENDS THE HEARING ON BEHALF OF THE APPLICANT, A NOTARIZED LETTER OF CONSENT MUST ACCOMPANY THE APPLICATION. ALL BOARD OF COUNTY COMMISSIONER PUBLIC HEARINGS WILL BE SCHEDULED FOR THE FOURTH TUESDAY OF EVERY MONTH. IF A QUORUM IS NOT AVAILABLE, THE HEARING WILL BE SCHEDULED THE NEXT AVAILABLE DATE. For County Use Only: Verification of Date of Delivery and County Receipt of Application Print ---PAGE BREAK--- Page 5 of 10 Grant of Easement within R.O.W. – Revised October 2025 APPENDIX A (Form A-1 thru A-8 to be completed on Survey and Mylar Plats only) FORM A-1: LEGAL DESCRIPTION AND CERTIFICATE OF OWNERSHIP LEGAL DESCRIPTION: (“Owner/s”) being the owner(s) of the real property of acres located in Park County, Colorado, descried as follows: [Insert surveyed property description of entire bounds of area being platted] In Witness Whereof, we do hereunto set our hands and seals this ___day of [Printed Name of Owner] [Printed Name of Owner] (If by corporation, a president sign, secretary attests and corporate seal is affixed) STATE OF ) ss. COUNTY OF Acknowledged before me this day of 20__, Notary Public Witness my hand and official seal. My Commission FORM A-2: SURVEYOR’S CERTIFICATE. SURVEYOR’S CERTIFICATE: I hereby certify that the survey and plat of the real property shown and described hereon were made by me or under my direct responsibility, supervision, and checking, in strict compliance with Colorado statures, and that both survey and plat are true, accurate and complete. [Insert if applicable statement by the land surveyor explaining how bearings were determined] [Insert if applicable statement by the land surveyor indicating the type of monuments used.] [Insert any required statement by the land surveyor certifying compliance with applicable provisions of the Colorado Revised Statutes] Colorado License No. Registered Land Surveyor Date: ---PAGE BREAK--- Page 6 of 10 Grant of Easement within R.O.W. – Revised October 2025 FORM A-3: APPROVAL FORM FOR BOARD OF COUNTY COMMISSIONERS APPROVAL BY BOARD OF COUNTY COMMISSIONERS: APPROVED by the Park County Board of County Commissioners, this day of 20__ subject to the provision that the County shall not undertake the maintenance of dedicated public streets, roads, and thoroughfares until satisfactory construction thereof by the subdivider. Said public streets, roads, and thoroughfares will be accepted by resolution at a regular county Commissioners’ meeting after completion, inspection, by Park County, and certification of construction in accordance with County standards. ATTEST: Park County Clerk and Recorder Chairperson FORM A-4: RECORDER’S CERTIFICATE RECORDER’S CERTIFICATE: This plat was filed for record in the office of the County Clerk and Recorder of Park County, on the day of 20__, and duly filed at Reception Park County Clerk and Recorder FORM A-5: TITLE COMPANY CERTIFICATE OF OWNERSHIP TITLE CERTIFICATE: Title Insurance Company hereby certifies that title to the above-described property is vested in the Owner(s). [Signature of Authorized Agent] FORM A-6: MORTGAGEE CONSENT TO DEDICATION MORTGAGEE CONSENT TO DEDICATION: The undersigned holders of mortgage interests and liens against the property offered for dedication and for transfer to the public and to Park County consents and approves of such dedication and transfer and subordinates and release its interests to such dedicated and transferred property In Witness Whereof, we do hereunto set our hands and seals this day of 20__ [Printed Name of Mortgage Interest Holder] (If by corporation, a president sign, secretary attests and corporate seal is affixed.) [Insert notarization conforming to applicable requirement of state law for mortgage’s place of execution] ---PAGE BREAK--- Page 7 of 10 Grant of Easement within R.O.W. – Revised October 2025 FORM A-7: COUNTY SKETCH PLAN OR PRELIMINARY PLAN APPROVAL PARK COUNTY APPROVAL APPROVED as a [insert either: Sketch Plan or Preliminary Plan] by the Park County Board of County Commissioners, this ___day of 20__ subject to all applicable provisions of the Park County Land Use Regulations. ATTEST: Park County Clerk and Recorder Chairperson FORM A-8: COUNTY ADMINISTRATIVE APPROVAL PARK COUNTY ADMINISTRATIVE APPROVAL: APPROVED as an Administrative Plat Amendment by the Planning Director of Park County Colorado and approved for recordation with the Park County Clerk and Recorder’s Office pursuant to the Park County Land Use Regulations this day of ATTEST: Planning Director/County Designee Park County Clerk and Recorder ---PAGE BREAK--- Page 8 of 10 Grant of Easement within R.O.W. – Revised October 2025 APPENDIX C AFFIDAVIT OF UNDERSTANDING I, the undersigned applicant, hereby acknowledge and agree to the following terms and conditions related to the submission of my application to the Park County Development Services Department. 1. ACKNOWLEDGMENT OF APPENDIX C REQUIREMENTS: I understand that, pursuant to Appendix C – Development Review Fees of the Park County Land Use Regulations, all application fees are non-refundable once an application has been received by the County, regardless of its status or outcome. 2. RESPONSIBILITY FOR COMPLETENESS: I acknowledge that it is solely my responsibility to ensure that all required materials, forms, maps, and supporting documentation are submitted in full compliance with the applicable Land Use Regulations and departmental procedures. 3. INCOMPLETE, WITHDRAWN, OR DENIED APPLICATIONS: I understand that any application that is incomplete, withdrawn, or denied—whether administratively or by action of the Board of County Commissioners—shall not be eligible for reimbursement, credit, or transfer of any portion of the fee paid. Any subsequent or corrected submittal shall constitute a new application and require payment of the applicable fee as set forth in Appendix C. 4. CERTIFICATION: I affirm that I have read and fully understand this affidavit and the non- refundable nature of the application fee as described in Appendix C. I further acknowledge that this affidavit shall be retained as part of the official record of my application. Applicant Name: Mailing Address: Project Name / Type: Signature of Applicant Print Name STATE OF ) ss. COUNTY OF Acknowledged before me this day of 20__, Notary Public Witness my hand and official seal. My Commission Expires: ---PAGE BREAK--- Page 9 of 10 Grant of Easement within R.O.W. – Revised October 2025 “POSTED” ADDRESS REQUIREMENTS Park County Land Use Regulation Section 7-1207 Address Number Signage Park County requires properties undergoing development to have a permanent address posted. This address post is permanent and is not just for the inspector but is for the use of the Fire Department, Sheriff and Emergency Services. The street address numbers need to be posted on the property prior to the preliminary inspection of the driveway. Numbers shall be attached to a 4” X 4” treated wood or redwood post. The post shall be placed at the driveway no further than 5 feet from the property line. Note: The post must not be placed in the county road right-of-way. The top of the post shall be installed, in a permanent fashion, a minimum of 48 inches above the ground. If the ground is frozen, place the post in a 5 gallon bucket filled with sand or rock until the post can be permanently installed into the ground. The sign specifications are shown with the below two examples. * Note: Contact your local Fire Protection District for signage information Type of Sign specifications for numbers is attached. 1 2 3 4 *Numbers attached to both sides of post 1 2 3 4 ---PAGE BREAK--- Page 10 of 10 Grant of Easement within R.O.W. – Revised October 2025 SIGN SPECIFICATIONS Standard Size - 6” x 18” Standard Color – Green Background with White Reflective Numbers