COLORADO DEPARTMENT OF TRANSPORTATION
STATE HIGHWAY ACCESS CODE - DESIGN WAIVER
State Highway No/Mp/SideLocal Jurisdiction
Region/Section/Patrol
Permit No. (if approved)
WHEN USED, THIS FORM SHALL BE ACCOMPANIED BY AN ACCESS PERMIT APPLICATION.
1. State specific reasons for this waiver request. Documents verifying statements should be provided with the request. State the specific sections of the State
Highway Access Code from which this request seeks relief. (Additional sheets may be attached). If waiver is temporary, state conditions which will change
allowing the access to conform to the access code. If date is known when conformance can be achieved, provide that date.
This form submitted by
(x)
Date
NOTICE: Providing false information to a government agency is punishable as perjury in the second degree, as well as being punishable under any other
applicable state or federal laws.
ITEMS BELOW THIS LINE ARE FOR OFFICE USE ONLY.
Date
Date
Date
Date
(x)
(x)
(x)
(x)
2. Recommendation of local government authority. When local government has issuing authority, this recommendation must be signed by an authorized
offical. (provide written statement)
3. Recommendation of region traffic and safety engineer or design engineer: (provide written statement)
4. Recommendation of the region access manager: (provide written statement)
FINAL ACTION TAKEN BY THE REGION TRANSPORTATION DIRECTOR:
Having reviewed this waiver request and all materials attached, I hereby approve, deny, this request for waiver from the design standards of the State
Highway Access Code. (signature shall be that of a registered professional engineer)
Previous editions are obsolete and may not be used CDOT Form # 112 05/17Copy distribution, required copies 1. Region permit files 2. Staff Access Section.
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