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�OMESTE RANGE Ip'4_ H 52 fl
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Homestead Gra'ige
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i022, Weld County Public Works Dept.
-4 111111 Street ACCESS PERMIT
•o,;��,�I- P.O. Box 758
GAF= - Greeley,Co 80632 APPLICATION FORM
t/C Q
WT Phone: (970)304-6496
Fax: (970)304-6497
Applicant Property
(- Property Owner(If different than Applicant)
J
Name !-I CJ, � n Name 6 rev1t MAJ.)a ( ITuu)a r,itrrprire,
•
b�Jn /r-t- /
Company 1}oniE ' ka i9)-tirs3 e .-a5 Address sees Lc9C& rP9
Address
� '/3SSo //wy 5t City $QoggeV\ State G) Zip SP0(eSrQ
lti City O p Pm State CO Zip d'0( S,,) Phone e'70 - 8/- OO4O
Business Phone Fax
Fax E-mail
E-mail 3 QIM'C s r4e ob,n f e ♦= Existing Access a=Proposed Access
Parcel Location&Sketch -
The access is on WCR 427 p
Nearest Intersection:WCR n 7 &t6iFff WCR I
Distance from Intersection
Parcel Number /481IO5000o33' '�
to
Section/Township/Range sy
//A (0 i ki0 '(` rc re
Is there an existing access to the property? 0 NO N 3 3
Number of Existing Accesses
Road Surface Type&Construction Information
Asphalt_ Gravel Treated Other r•
Culvert Size &Type - se 2eces3 po';rsi,J
WO-C. rt7d LA.rx
Materials used to construct Access
Lo'+C-PE —(2563
•
• Construction Start Date Finish Date
Proposed Use
o Temporary (Tracking Pad Required)/$75 o Single Residential/$75 o Industrial/$150
o Small Commercial or Oil&Gas/$75 o Large Commercial/$150 o Subdivision/$150
❑ Field (Agriculture Only)/Exempt
Is this access associated with a Planning Process? ❑ No o USR ❑ RE ❑PUD o Other
Required Attached Documents
-Traffic Control Plan -Certificate of Insurance -Access Pictures (From the Left, Right, &into the access)
By accepting this permit,the undersigned Applicant,under penalty of perjury,verifies that they have received all pages of the permit
application;they have read and understand all of the permit requirements and provisions set forth on all pages;that they have the
authority to sign for and bind the Applicant, if the Applicant is a corporation or other entity; and that by virtue of their signature the
• Applicant is bound by and agrees to comply with all said permit requirements and provisions,all Weld County ordinances,and state laws
regarding facilities construction.
Signature .,,r, (3 Printed Name ring a L-0Hrja'ek, Date 7' ( f .. ii
Approval or Denial will be issued in minimum of 5 days. Approved by
Revised Date 6/29/10
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