Form TR-0100 "Standard Encroachment Permit Application" - California

What Is Form TR-0100?

This is a legal form that was released by the California Department of Transportation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2018;
  • The latest edition provided by the California Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form TR-0100 by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

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Page 1 of 4
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
STANDARD ENCROACHMENT PERMIT APPLICATION
FOR CALTRANS USE
TR-0100 (REV 12/2018)
TRACKING NO.
Complete ALL fields, write "N/A" if not applicable. Type or print clearly.
DIST/CO/RTE/PM
This application is not complete until all requirements have been approved.
Permission is requested to encroach on the State Highway right-of-way as follows:
SIMPLEX STAMP
1. COUNTY
2. ROUTE
3. POST MILE
4. ADDRESS OR STREET NAME
5. CITY
6. CROSS STREET (Distance and direction from project site)
DATE OF SIMPLEX STAMP
7. WORK TO BE PERFORMED BY
8. IS THIS APPLICATION FOR THE CONTRACTOR'S (DOUBLE) PERMIT?
APPLICANT
CONTRACTOR
NO
YES. If "YES", provide the Parent Permit Number
9. ESTIMATE START DATE
10. ESTIMATED COMPLETION DATE
11. ESTIMATED NUMBER OF WORKING DAYS WITHIN STATE HIGHWAY RIGHT-OF-WAY
12. ESTIMATED CONSTRUCTION COSTS WITHIN STATE HIGHWAY RIGHT-OF-WAY
13. HAS THE PROJECT BEEN REVIEWED BY ANOTHER CALTRANS BRANCH?
NO
YES. If "YES", which branch?
14. FUNDING SOURCE(S)
FEDERAL
STATE
LOCAL
PRIVATE
SB 1 (ROAD REPAIR AND ACCOUNTABILITY ACT OF 2017)
15. CALTRANS PROJECT CODE (ID)
16. APPLICANT'S REFERENCE / UTILITY WORK ORDER NUMBER
17. DESCRIBE WORK TO BE DONE WITHIN STATE HIGHWAY RIGHT-OF-WAY (in 20 lines or less)
Attach 6 complete sets of plans (folded to 8.5" x 11") and any applicable specifications, calculations, maps, traffic control plans, etc.
18 (a). PORTION OF STATE HIGHWAY RIGHT-OF-WAY WHERE WORK IS BEING PROPOSED (check all that apply)
Traffic lane
Shoulder
Sidewalk
Median
At or near an intersection
Mobile work
Outside of the shoulder,
feet from edge of pavement
Other
18 (b). PROPOSED TRAFFIC CONTROL PLANS AND METHOD
No traffic control needed
State Standard Plans (T-Sheets) #
Project specific Traffic Control Plans included
To be submitted by contractor
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
Copyright 2018 California Department of Transportation. All rights reserved.
Page 1 of 4
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
STANDARD ENCROACHMENT PERMIT APPLICATION
FOR CALTRANS USE
TR-0100 (REV 12/2018)
TRACKING NO.
Complete ALL fields, write "N/A" if not applicable. Type or print clearly.
DIST/CO/RTE/PM
This application is not complete until all requirements have been approved.
Permission is requested to encroach on the State Highway right-of-way as follows:
SIMPLEX STAMP
1. COUNTY
2. ROUTE
3. POST MILE
4. ADDRESS OR STREET NAME
5. CITY
6. CROSS STREET (Distance and direction from project site)
DATE OF SIMPLEX STAMP
7. WORK TO BE PERFORMED BY
8. IS THIS APPLICATION FOR THE CONTRACTOR'S (DOUBLE) PERMIT?
APPLICANT
CONTRACTOR
NO
YES. If "YES", provide the Parent Permit Number
9. ESTIMATE START DATE
10. ESTIMATED COMPLETION DATE
11. ESTIMATED NUMBER OF WORKING DAYS WITHIN STATE HIGHWAY RIGHT-OF-WAY
12. ESTIMATED CONSTRUCTION COSTS WITHIN STATE HIGHWAY RIGHT-OF-WAY
13. HAS THE PROJECT BEEN REVIEWED BY ANOTHER CALTRANS BRANCH?
NO
YES. If "YES", which branch?
14. FUNDING SOURCE(S)
FEDERAL
STATE
LOCAL
PRIVATE
SB 1 (ROAD REPAIR AND ACCOUNTABILITY ACT OF 2017)
15. CALTRANS PROJECT CODE (ID)
16. APPLICANT'S REFERENCE / UTILITY WORK ORDER NUMBER
17. DESCRIBE WORK TO BE DONE WITHIN STATE HIGHWAY RIGHT-OF-WAY (in 20 lines or less)
Attach 6 complete sets of plans (folded to 8.5" x 11") and any applicable specifications, calculations, maps, traffic control plans, etc.
18 (a). PORTION OF STATE HIGHWAY RIGHT-OF-WAY WHERE WORK IS BEING PROPOSED (check all that apply)
Traffic lane
Shoulder
Sidewalk
Median
At or near an intersection
Mobile work
Outside of the shoulder,
feet from edge of pavement
Other
18 (b). PROPOSED TRAFFIC CONTROL PLANS AND METHOD
No traffic control needed
State Standard Plans (T-Sheets) #
Project specific Traffic Control Plans included
To be submitted by contractor
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
Copyright 2018 California Department of Transportation. All rights reserved.
Page 2 of 4
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
STANDARD ENCROACHMENT PERMIT APPLICATION
TRACKING NO.
TR-0100 (REV 12/2018)
19.
MAX. DEPTH (in) MIN. DEPTH (in) AVG. WIDTH (in) LENGTH (ft)
SURFACE TYPE (e.g. Asphalt, concrete, soil, etc.)
EXCAVATION
20.
PRODUCT BEING TRANSPORTED CARRIER PIPE
CASING PIPE
(in.)
(in.)
MATERIAL
DIAMETER
MATERIAL
DIAMETER
PIPES
PROPOSED INSTALLATION METHOD (e.g. HDD, Bore & Jack, Open Cut, etc.)
VOLTAGE / PSIG
DOES THE PROPOSED PROJECT INVOLVE THE REPLACEMENT AND/OR ABANDONMENT OF AN EXISTING FACILITY?
NO
YES. If "YES", provide a description
21. IS A CITY, COUNTY OR OTHER PUBLIC AGENCY INVOLVED IN THE APPROVAL OF THIS PROJECT?
YES (if "YES", check the type of project AND attach the environmental documentation and conditions of approval)
COMMERCIAL DEVELOPMENT
BUILDING
GRADING
OTHER
CATEGORICALLY EXEMPT
NEGATIVE DECLARATION
ENVIRONMENTAL IMPACT REPORT
OTHER
NO (if "NO", check the category below which best describes the project AND answer questions A-K)
DRIVEWAY OR ROAD APPROACH, RECONSTRUCTION,
FENCE
EROSION CONTROL
MAINTENANCE OR RESURFACING
PUBLIC UTILITY MODIFICATION, EXTENSIONS, HOOKUPS
MAILBOX
LANDSCAPING
FLAGS, SIGNS, BANNERS, DECORATIONS, PARADES AND CELEBRATIONS
OTHER
The following questions must be answered when a City, County or other public agency IS NOT involved in the approval of this project.
Your answers to these questions will assist Caltrans staff in identifying any physical, biological, social or economic resources that may be affected
by your proposed project within State Highway right-of-way and to determine which type of environmental studies may be required to approve
your application for an encroachment permit. It is the applicant's responsibility for the production of all required environmental documentation and
supporting studies and in some cases this may be costly and time consuming. If possible, attach photographs of the location of the proposed
project. Answer these questions to the best of your ability. Provide a description of any "YES" answers (type, name, number, etc.).
A. Will any existing vegetation and/or landscaping within State Highway right-of-way be disturbed?
B. Are there waterways (e.g. river, creek, pond, natural pool or dry streambed) adjacent to or within the limits of the proposed project?
C. Is the proposed project located within five miles of the coast line?
D. Will the proposed project generate construction noise levels greater than 86 decibels (dBA) (e.g. Jack-hammering, pile driving)?
E. Will the proposed project incorporate land from a public park, recreation area or wildlife refuge open to the public?
F. Are there any recreational trails or paths within the limits of the proposed project?
G. Will the proposed project impact any structures, buildings, rail lines or bridges within State Highway right-of-way?
H. Will the proposed project impact access to any businesses or residences?
I. Will the proposed project impact any existing public utilities or public services?
J. Will the proposed project impact any existing pedestrian facilities, such as sidewalks, crosswalks or overcrossings?
K. Will new lighting be constructed within or adjacent to State Highway right-of-way?
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
Page 3 of 4
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
STANDARD ENCROACHMENT PERMIT APPLICATION
TRACKING NO.
TR-0100 (REV 12/2018)
22. Will the proposed project cause a substantial change in the significance of a historical resource (45 years or older),
or cultural resource?
(if "YES", provide a description)
YES
NO
23. Will the proposed project be on an existing State Highway or street where the activity involves removal of a scenic resource? (e.g. A
significant tree or stand of trees, a rock outcropping or a historic building)
YES
NO
(if "YES", provide a description)
24. Is work being done on the applicant's property in addition to State Highway right-of-way?
YES
NO
(If "YES", attach 6 complete sets of site and grading plans)
25. Will the proposed project require the disturbance of soil?
YES
NO
If "YES", estimate the area of disturbed soil within State Highway right-of-way in acres:
and estimate the area of disturbed soil outside State Highway right-of-way in acres:
26. Will the proposed project require dewatering?
YES
NO
(gallons/month)
If "YES", estimate Total gallons AND gallons/month.
(Total gallons) AND
STORMWATER
NON-STORMWATER
SOURCE*:
(*See Caltrans SWMP for definition of non-storm water discharge:
http://www.dot.ca.gov/env/stormwater/
)
27. How will any storm water or ground water be disposed?
Storm Drain System
Combined Sewer / Stormwater System
Stormwater Retention Basin
N/A
Other (explain)
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
Page 4 of 4
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
STANDARD ENCROACHMENT PERMIT APPLICATION
TRACKING NO.
TR-0100 (REV 12/2018)
READ THE FOLLOWING CLAUSES PRIOR TO SIGNING THIS ENCROACHMENT PERMIT APPLICATION.
The applicant’s submission of this application to the California Department of Transportation constitutes the applicant’s agreement and
representation that the work or other activity contemplated by the encroachment permit application shall comply with all applicable standards,
specifications, policies, requirements, conditions, and regulations of the California Department of Transportation, and the applicant understands
the application may be denied if there is non-compliance with any of the above. An exception process exists and may result in approval of a
non-compliant encroachment, in the discretion of the California Department of Transportation, but the exception process may require additional
time to complete. The applicant understands and agrees all work or other activity contemplated by the encroachment permit application is
subject to inspection and oversight by the California Department of Transportation. The applicant understands and agrees encroachment permit
fees must still be paid if an application is withdrawn or denied. The applicant understands a denial may be appealed, in accordance with
California Streets and Highways Code, Section 671.5, and the related regulations found in California Code of Regulations, Title 21, Division 2,
Chapter 8, Article 2.
The applicant understands and agrees that immediately upon issuance of the encroachment permit the applicant is bound by, subject to, and
must comply with the "Encroachment Permit General Provisions" (TR-0045), "Stormwater Special Provisions" (TR-0400) and any other
applicable Special Provisions and Conditions of the encroachment permit. The "Encroachment Permit General Provisions" (TR-0045), and the
Stormwater Special Provisions (TR-0400) are available at: http://www.dot.ca.gov/trafficops/ep/docs/Appendix_K_(WEB).pdf. If a paper copy is
needed of the "Encroachment Permit General Provisions" (TR-0045) and/or "Stormwater Special Provisions" (TR-0400), please contact the
District Office of Encroachment Permits. Their contact information is available at:
http://www.dot.ca.gov/trafficops/ep/docs/
Appendix_G_(WEB).pdf. The "Encroachment Permit General Provisions" (TR-0045) and any other applicable Special Provisions and
Conditions will be provided as part of the encroachment permit. Information about Stormwater requirements is available at the Internet address:
http://www.dot.ca.gov/hq/construc/stormwater/.
The applicant understands an encroachment permit may be denied, revoked, and/or a bond may be required, for non-payment of prior or
present encroachment permit fees. An encroachment permit is not a property right and does not transfer with the property to a new owner.
Each of the persons purporting to execute this application on behalf of the applicant and/or on behalf of the applicant’s authorized agent or
engineer represents and warrants such person has full and complete legal authority to do so and to thereby bind applicant to the terms and
conditions herein and to the terms and/or conditions of the encroachment permit. Applicant understands and agrees this application may be
executed in one or more counterparts, each of which shall be deemed an original, but all of which together shall constitute one and the same
instrument. Executed copies of this application and/or its counterparts may be reproduced and/or exchanged by copy machine, mailing,
facsimile, or electronic means (such as e-mail), and such copies shall be deemed to be effective as originals.
28. NAME OF APPLICANT (Project or Property Owner or Organization)
ADDRESS OF APPLICANT (Include City, State and Zip Code)
E-MAIL ADDRESS
PHONE NUMBER
FAX NUMBER
29. NAME OF AUTHORIZED AGENT / ENGINEER
IS A LETTER OF
(A "Letter of Authorization" is required if different from #28)
AUTHORIZATION ATTACHED?
YES
NO
ADDRESS OF AUTHORIZED AGENT / ENGINEER (Include City, State and Zip Code)
E-MAIL ADDRESS
PHONE NUMBER
FAX NUMBER
30. NAME OF BILLING CONTACT ( Same as #28
)
Same as #29
BILLING ADDRESS WHERE INVOICE(S) IS / ARE TO BE MAILED (Include City, State and Zip Code)
E-MAIL ADDRESS
PHONE NUMBER
FAX NUMBER
* I hereby certify under penalty of perjury under the laws of the State of California that the information in this application and any document
submitted with or in support of this application are true and correct to the best of my knowledge and belief, and that copies of any documents
submitted with or in support of this application are true and correct copies of unaltered original documents. I further understand that if I have
provided information that is false, intentionally incomplete, or misleading I may be charged with a crime and subjected to fine or imprisonment,
or both fine and imprisonment. (Penal Code Section 72)
31. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT*
32. PRINT OR TYPE NAME
33. TITLE
34. DATE
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
STANDARD ENCROACHMENT PERMIT APPLICATION
TR-0100 (REV 12/2018)
INSTRUCTIONS
Complete ALL fields, write "N/A" if not applicable. Type or print clearly.
All dimensions must be in U.S. Customary (English) units.
Print your application single sided and submit all of the required attachments (See Section VII A&B of the "Encroachment Permit Application
Guide Booklet" found at: http://www.dot.ca.gov/trafficops/ep/docs/EP_Application_Guide_Booklet.pdf).
1. County (e.g. Fresno, San Francisco, Los Angeles, etc.)
Replacement and/or abandonment of an existing facility (e.g. Abandoning
pipe and filling it with two-sack slurry cement)
2. State Highway Route Number (e.g. I-5, SR-99, etc.)
21. Check “YES”, if you are getting a permit or approval from another agency
(City, County, etc.), and an environmental determination has been made.
3. Highway Postmile: (location of work, see https://postmile.dot.ca.gov/)
Then check the Categorically Exempt, Negative Declaration,
If unable to determine, contact the appropriate District Encroachment
Environmental Impact Report box or Other if one has been prepared.
Permits Office for assistance at:
http://www.dot.ca.gov/trafficops/ep/
Attach a copy of the approved document and a copy of the Notice of
docs/Appendix_G_(WEB).pdf
Determination. Skip questions A-K.
4. Address of project site (if the property has a physical address with a
If you checked “NO”, check the box of the appropriate type of work to be
Number and Street/Road Name)
done,or check “other” and fill in the type of work to be done. Also answer
questions A-K.
5. City (e.g. Sacramento, Redding, Irvine, etc.)
22. A Historical Resource includes, but is not limited to, any object, building,
6. Distance and the direction from the nearest cross street to the project
structure, site, area, place, record, or manuscript that has historical or
site (e.g. 500 ft. north of "C" Street).
archaeological significance, or significance in the architectural, engineering,
scientific, economic, agricultural, educational, social, political, military, or
7. Indicate whether the work will be performed by the applicant (your own
cultural annals of California.
forces) or by a contractor.
23. In this context a Scenic Resource includes, but is not limited to, trees
8. Indicate if you are applying for a "Contractor's (Double) Permit" and
that display outstanding features of form or age; unique, massive rock
provide the “Parent Permit Number”.
formations; historic buildings that are rare examples of their period, style,
design, or which have special architectural features and details of
9. Estimated start date for the proposed work. (Allow a minimum of 60
importance.
calendar days from the submittal date of your application for processing)
24. Is there any work being done on the applicant’s property?
10. Estimated completion date for the proposed work.
25. Indicate if the proposed project will require the disturbance of soil. If “YES,”
11. Estimated number of working days within State Highway right-of-way.
estimate the area within AND outside of State Highway right-of-way in
acres.
12. Estimated construction costs for all work to be done within State
Highway right-of-way.
26. Indicate if the proposed project will require dewatering. If “YES,”
estimate volume in total gallons AND gallons per month. Also indicate
13. Has another Caltrans' branch seen or reviewed your project? Which
the source: Stormwater or Non-Stormwater (see Caltrans Stormwater
branch? (e.g. Design, Project Management, Right-of-Way,
Management Plan for definitions of non-stormwater discharge at:
Environmental, etc.)
http://www.dot.ca.gov/hq/env/stormwater).
14. Identify funding source(s) for the proposed work.
27. Indicate how any stormwater or ground water will be disposed of from
or near the limits of the proposed project.
15. Caltrans’ Project Code (ID) if this is a State project, capital project, or
joint venture project.
28. Name of the applicant or organization applying for the permit. List the
mailing address, e-mail address, phone and fax numbers.
16. Your company’s reference number or utility work order number for this
project.
29. Name of the authorized agent or engineer acting on behalf of the
applicant or organization. Attach a letter of authorization signed by the
17. Describe the proposed work to be done entirely. If applicable, attach
applicant or organization. List the mailing address, e-mail address,
six (6) complete sets of FOLDED plans (folded 8-½” X 11”) and any
phone and fax numbers.
applicable specifications, calculations, maps, etc.
30. Name of the billing contact. List the mailing address where invoices
18. (a) Identify portion(s) of State right-of-way where work will occur and
are to be mailed, email address, phone and fax numbers.
(b) proposed traffic control plans to be used if any.
31. Signature of the applicant or applicant's authorized agent.
19. Maximum and minimum depth, average width, and length of the
excavation area. Existing surface type (e.g. Asphalt, concrete, soil, etc.)
32. Name of the applicant or applicant's authorized agent.
20. Product being transported (e.g. water, natural gas, etc.)
33. Title (owner, president, etc.) of the applicant or applicant's authorized
Carrier pipe, diameter (inches) and material (e.g. Steel, HDPE, etc.)
agent.
Casing pipe (if any), diameter and material Proposed installation
34. Date of the signature.
method, Voltage of electrical current or pressure of liquid or gas.
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
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