Form CEM-5773 "Americans With Disabilities Act (Ada) Project Compliance Certification" - California

What Is Form CEM-5773?

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 November 1, 2017;
  • 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 CEM-5773 by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

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Download Form CEM-5773 "Americans With Disabilities Act (Ada) Project Compliance Certification" - California

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
AMERICANS WITH DISABILITY ACT (ADA) PROJECT COMPLIANCE CERTIFICATION
Page 1 of 3
CEM-5773 (NEW 11/2017)
PROJECT INFORMATION/NAME
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
CONTRACTOR NAME
ADA PROJECT COMPLIANCE CERTIFICATION
PROJECT ENGINEER
To ensure pedestrian facilities are compliant with Americans with Disabilities Act (ADA) the following applies to this project:
There were no pedestrian facilities altered or constructed within the state right-of-way on this project.
The required pedestrian facilities were designed in accordance with the ADA standards in Design Information Bulletin 82, "Pedestrian
Accessibility Guidelines for Highway Projects."
The resident engineer proposed changes that resulted in modifications to the ADA elements. The modified ADA elements were re-designed
in compliance to ADA standards in DIB 82.
ADA DESIGN COMPLIANCE CERTIFICATION
I certify that the pedestrian facilities have been designed in compliance with the ADA standards in DIB 82 for the above referenced project.
PROJECT ENGINEER (print name)
SIGNATURE
DATE
RESIDENT ENGINEER
ADA CONSTRUCTION COMPLIANCE CERTIFICATION
I certify that there were no pedestrian facilities altered or constructed within the state right-of-way on this project.
I certify that the pedestrian facilities locations shown on ADA PEDESTRIAN FACILITIES SUMMARY pages have been constructed in
accordance with the plans and specifications for the above referenced project.
I certify that the pedestrian facilities locations shown on ADA PEDESTRIAN FACILITIES SUMMARY pages have been constructed in
accordance with the plans and specifications and any noncompliant pedestrian facilities were reviewed by the district ADA engineer and
determined to be in compliance with the ADA standards in DIB 82.
RESIDENT ENGINEER (print name)
SIGNATURE
DATE
ADA PROJECT COMPLIANCE CERTIFICATION SUBMITTAL
Submit ADA Project Compliance Certification forms with attachments to the ADA Infrastructure Program at:
ADA.Compliance.Office@dot.ca.gov
SUBMITTED BY (print name)
SIGNATURE
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
AMERICANS WITH DISABILITY ACT (ADA) PROJECT COMPLIANCE CERTIFICATION
Page 1 of 3
CEM-5773 (NEW 11/2017)
PROJECT INFORMATION/NAME
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
CONTRACTOR NAME
ADA PROJECT COMPLIANCE CERTIFICATION
PROJECT ENGINEER
To ensure pedestrian facilities are compliant with Americans with Disabilities Act (ADA) the following applies to this project:
There were no pedestrian facilities altered or constructed within the state right-of-way on this project.
The required pedestrian facilities were designed in accordance with the ADA standards in Design Information Bulletin 82, "Pedestrian
Accessibility Guidelines for Highway Projects."
The resident engineer proposed changes that resulted in modifications to the ADA elements. The modified ADA elements were re-designed
in compliance to ADA standards in DIB 82.
ADA DESIGN COMPLIANCE CERTIFICATION
I certify that the pedestrian facilities have been designed in compliance with the ADA standards in DIB 82 for the above referenced project.
PROJECT ENGINEER (print name)
SIGNATURE
DATE
RESIDENT ENGINEER
ADA CONSTRUCTION COMPLIANCE CERTIFICATION
I certify that there were no pedestrian facilities altered or constructed within the state right-of-way on this project.
I certify that the pedestrian facilities locations shown on ADA PEDESTRIAN FACILITIES SUMMARY pages have been constructed in
accordance with the plans and specifications for the above referenced project.
I certify that the pedestrian facilities locations shown on ADA PEDESTRIAN FACILITIES SUMMARY pages have been constructed in
accordance with the plans and specifications and any noncompliant pedestrian facilities were reviewed by the district ADA engineer and
determined to be in compliance with the ADA standards in DIB 82.
RESIDENT ENGINEER (print name)
SIGNATURE
DATE
ADA PROJECT COMPLIANCE CERTIFICATION SUBMITTAL
Submit ADA Project Compliance Certification forms with attachments to the ADA Infrastructure Program at:
ADA.Compliance.Office@dot.ca.gov
SUBMITTED BY (print name)
SIGNATURE
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
AMERICANS WITH DISABILITY ACT (ADA) PROJECT COMPLIANCE CERTIFICATION
Page 2 of 3
CEM-5773 (NEW 11/2017)
ADA PEDESTRIAN FACILITIES SUMMARY
ADA Facility Information
Location
Pedestrian Facility
County
City
Route
Number
Curb Ramp
Passageway
Route Name
Cross Street
Sidewalk
Longitude (x)
Latitude (y)
Postmile/Station
Driveway
Parking
Is the first page of compliance inspection report attached to project compliance certification?
Yes
No
Location
Pedestrian Facility
County
City
Route
Number
Curb Ramp
Passageway
Route Name
Cross Street
Sidewalk
Longitude (x)
Latitude (y)
Postmile/Station
Driveway
Parking
Is the first page of compliance inspection report attached to project compliance certification?
Yes
No
Location
Pedestrian Facility
County
City
Route
Number
Curb Ramp
Passageway
Route Name
Cross Street
Sidewalk
Longitude (x)
Latitude (y)
Postmile/Station
Driveway
Parking
Is the first page of compliance inspection report attached to project compliance certification?
Yes
No
Location
Pedestrian Facility
County
City
Route
Number
Curb Ramp
Passageway
Route Name
Cross Street
Sidewalk
Longitude (x)
Latitude (y)
Postmile/Station
Driveway
Parking
Is the first page of compliance inspection report attached to project compliance certification?
Yes
No
Location
Pedestrian Facility
County
City
Route
Number
Curb Ramp
Passageway
Route Name
Cross Street
Sidewalk
Driveway
Longitude (x)
Latitude (y)
Postmile/Station
Parking
Is the first page of compliance inspection report attached to project compliance certification?
Yes
No
Add additional ADA Pedestrian Facilities Summary sheets as necessary.
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
AMERICANS WITH DISABILITY ACT (ADA) PROJECT COMPLIANCE CERTIFICATION
Page 3 of 3
CEM-5773 (NEW 11/2017)
GENERAL INFORMATION
This form is to provide documentation that permanent pedestrian facilities constructed meet ADA requirements.
The Americans with Disabilities Act (ADA) of 1990, along with its implementing regulations, and the California Government Code
Sections 4450 et seq. prescribe that facilities shall be made accessible to persons with disabilities.
Design Information Bulletin 82, “Pedestrian Accessibility Guidelines for Highway Projects” is Caltrans policy for design requirements to
ensure that Caltrans projects comply with state and federal laws, regulations, and codes regarding pedestrian accessibility.
Contact the district ADA coordinator for additional information about ADA requirements.
FORM
CONTRACT NUMBER/CO/RTE/PM: For local agency encroachment permit projects, write the encroachment permit number in the
CONTRACT NUMBER field.
PROJECT IDENTIFICATION NUMBER: For Caltrans projects use the Project Identification Number. For local agency encroachment
permit projects, write N/A in the field.
On the project ADA Pedestrian Facilities Summary list all locations where ADA pedestrian facilities were constructed including:
Curb Ramps
Passageways
Sidewalks
Driveways
Parking
For each ADA facility location provide:
Location Number
County
City
Route
Route Name (e.g. State Route 49)
Name of the cross street. For mid-block curb ramp, write N/A for cross street.
Latitude and longitude must be in decimal format to a minimum of six decimal places. Free GPS applications for smart phones, tablets,
and desk tops will report latitudes and longitudes to the necessary accuracy for differentiation of the permanent pedestrian facilities
locations.
Add additional ADA Pedestrian Facilities Summary sheets as necessary.
Attach the first page of the compliance inspection report for each location to this project compliance certification.
ADA PROJECT COMPLIANCE CERTIFICATION
When the pedestrian facilities are completed, request the project engineer complete the first part of the form.
The resident engineer must review the compliance inspection reports for all locations of constructed pedestrian facilities and determine
if the project is ADA compliant based on:
1.
All pedestrian facilities were constructed in compliance with the plans and specifications, or
2.
Pedestrian facilities noncompliant with the plans and specifications have been determined ADA compliant by the district ADA
engineer's review and evaluation shown on the compliance inspection reports.
Upon ADA project compliance certification completion, the resident engineer must file the ADA project compliance certification in the
project records and transmit the form with attachments to ADA.Compliance.Office@dot.ca.gov.
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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