Form CEM-5773CH "Curb Ramp (Case Ch) Americans With Disabilities Act (Ada) Compliance Inspection Report" - California

What Is Form CEM-5773CH?

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;
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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
CURB RAMP (CASE CH) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 1 of 8
CEM-5773CH (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
CURB RAMP INFORMATION
Location Number
County
City
Route
Route Name
Cross Street
Postmile/Station
Intersection Control
Construction Type
Ramp
Latitude (y)
None
New
Single
Longitude (x)
Street Grade (%)
Stop/Yield
Retrofit
Dual Ramp 1
Signalized
Dual Ramp 2
Intersection Quadrant
Applicable Standard Plans
Applicable Standard Specifications
Northwest
2015 Standard Plan A88B
2010
Northeast
2015 Revised Standard Plan A88B Dated:
2015
Southwest
Other
Other
Southeast
Applicable Design Bulletin
DIB 82-05
Mid-Block
ADA CURB RAMP COMPLIANCE CERTIFICATION
Based on the field measurements shown on page 2 curb ramp complies with standard plan A88B?
Yes
No
Based on the field measurements shown on page 3 curb ramp complies with standard plan A88B?
Yes
No
Curb ramp is ADA compliant based on ADA curb ramp check list shown on page 4?
Yes
No
Curb ramp is ADA compliant based on ADA curb ramp check list shown on page 5?
Yes
No
Curb ramp is ADA compliant based on ADA curb ramp check list shown on page 6?
Yes
No
This section must be completed if no is marked for any question indicating that a curb ramp is non-compliant.
District ADA engineer compliance determination (must state ADA standard used for compliance determination):
Curb ramp is ADA compliant with ADA standards
Yes
No
District ADA Engineer (print name)
Signature
Date
RESIDENT ENGINEER ADA COMPLIANCE CERTIFICATION
I have reviewed the curb ramp inspection report and find that the constructed curb ramp is in compliance with ADA standards.
Resident Engineer (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
CURB RAMP (CASE CH) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 1 of 8
CEM-5773CH (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
CURB RAMP INFORMATION
Location Number
County
City
Route
Route Name
Cross Street
Postmile/Station
Intersection Control
Construction Type
Ramp
Latitude (y)
None
New
Single
Longitude (x)
Street Grade (%)
Stop/Yield
Retrofit
Dual Ramp 1
Signalized
Dual Ramp 2
Intersection Quadrant
Applicable Standard Plans
Applicable Standard Specifications
Northwest
2015 Standard Plan A88B
2010
Northeast
2015 Revised Standard Plan A88B Dated:
2015
Southwest
Other
Other
Southeast
Applicable Design Bulletin
DIB 82-05
Mid-Block
ADA CURB RAMP COMPLIANCE CERTIFICATION
Based on the field measurements shown on page 2 curb ramp complies with standard plan A88B?
Yes
No
Based on the field measurements shown on page 3 curb ramp complies with standard plan A88B?
Yes
No
Curb ramp is ADA compliant based on ADA curb ramp check list shown on page 4?
Yes
No
Curb ramp is ADA compliant based on ADA curb ramp check list shown on page 5?
Yes
No
Curb ramp is ADA compliant based on ADA curb ramp check list shown on page 6?
Yes
No
This section must be completed if no is marked for any question indicating that a curb ramp is non-compliant.
District ADA engineer compliance determination (must state ADA standard used for compliance determination):
Curb ramp is ADA compliant with ADA standards
Yes
No
District ADA Engineer (print name)
Signature
Date
RESIDENT ENGINEER ADA COMPLIANCE CERTIFICATION
I have reviewed the curb ramp inspection report and find that the constructed curb ramp is in compliance with ADA standards.
Resident Engineer (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
CURB RAMP (CASE CH) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 2 of 8
CEM-5773CH (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
Route Name
Intersection Quadrant
Ramp
Northwest
Southwest
Single
Cross Street
Northeast
Southeast
Dual Ramp 1
Mid-Block
Dual Ramp 2
ADA CURB RAMP (CASE CH) FIELD MEASUREMENTS
Measure and verify the dimensions and slopes:
Landing
Landing
Landing
Landing
Gutter
Gutter
Road Surface
Slope
Cross Slope
Width
Depth
Cross Slope
Slope
Cross Slope
(x.x%)
(x.x%)
(inches)
(inches)
(x.x%)
(x.x%)
within 2'
from Ramp
(x.x%)
A1
B1
C1
D1
E1
F1
G1
A2
B2
C2
D2
E2
F2
G2
A3
B3
C3
D3
1.7% or less?
1.7% or less?
59.75" or
47.75" or
4.4% or less?
1.7% or less?
5.2% or less?
greater?
greater?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
N/A
Gutter is 24" or
more in width.
Remarks
Inspection 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
CURB RAMP (CASE CH) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 3 of 8
CEM-5773CH (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
Route Name
Intersection Quadrant
Ramp
Northwest
Southwest
Single
Cross Street
Northeast
Southeast
Dual Ramp 1
Mid-Block
Dual Ramp 2
ADA CURB RAMP (CASE CH) FIELD MEASUREMENTS
Measure and verify the dimensions and slopes:
Ramp
Ramp
Ramp
Detectable
Detectable
Conforming Sidewalk
Conforming Sidewalk
Slope
Cross Slope
Width
Warning
Warning
Slope within 4'
Cross Slope within 4'
(x.x%)
(x.x%)
(inches)
Surface Width
Surface Depth
of ramp
of ramp
(inches)
(inches)
(x.x%)
(x.x%)
H1
I1
J1
K1
L1
M1
N1
H2
I2
J2
K2
L2
M2
N2
H3
I3
J3
M3
7.7% or less?
1.7% or less?
47.75" or
Extends full
Minimum 36"?
5.2% or less?
1.7% or less?
greater?
width?
Yes
No
Yes
No
If "No," is the sidewalk
If "No," is the conforming
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
adjacent to the roadway
sidewalk a transition to an
and the sidewalk grade
existing sidewalk?
Yes
No
does not exceed the
roadway grade?
If "Yes," the 1.7% or less
Yes
No
N/A
requirement does not apply.
Remarks
Inspection 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
CURB RAMP (CASE CH) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 4 of 8
CEM-5773CH (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
Route Name
Intersection Quadrant
Ramp
Northwest
Southwest
Single
Cross Street
Northeast
Southeast
Dual Ramp 1
Mid-Block
Dual Ramp 2
ADA CURB RAMP (CASE CH) FIELD INSPECTION CHECKLIST
No.
Requirement
Compliant
Photo
Remarks
1
Detectable warning surface was on the Authorized Material List?
Yes
No
Yes
No
Yes
No
2
Detectable warning surface is yellow in color?
Yes
No
Yes
No
Yes
No
Detectable warning surface is in compliance with standard
3
plan A88A detail Raised Truncated Dome for dome diameter
Yes
No
Yes
No
Yes
No
and height?
Detectable warning surface is in compliance with standard
4
plan A88A detail Detectable Warning Surface for truncated
Yes
No
Yes
No
Yes
No
dome spacing?
Detectable warning surface edge nearest the street is in
5
contact with the back of curb projection? If answer is yes,
Yes
No
Yes
No
Yes
No
then mark item 6 N/A.
Detectable warning surface edge nearest the street is
Yes
No
6
installed as shown on the project plans?
Yes
No
Yes
No
N/A
Mark N/A if installed per standard plan.
Detectable warning surface 5-year manufacturer's warranty
7
Yes
No
Yes
No
is on file?
Curb ramp surface has a broom finish, which provides slip
Yes
No
Yes
No
Yes
No
8
resistant surface?
9
Are all changes in surface level less than ¼”?
Yes
No
Yes
No
Yes
No
For any utility pull boxes, manholes, or vaults within the
boundary of curb ramp are they flush with the finished curb
Yes
No
10
ramp surface?
Yes
No
Yes
No
N/A
Mark item N/A if there are no utility pull boxes, manholes, or
vaults.
For openings or gratings located within the boundary of curb
ramp, are spaces less than ½” in one direction and are
Yes
No
Yes
No
Yes
No
11
elongated openings oriented perpendicular to dominate
N/A
direction of travel?
Mark item N/A if there are no openings or gratings.
Remarks
Field inspection checklist completed 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
CURB RAMP (CASE CH) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 5 of 8
CEM-5773CH (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
Route Name
Intersection Quadrant
Ramp
Northwest
Southwest
Single
Cross Street
Northeast
Southeast
Dual Ramp 1
Mid-Block
Dual Ramp 2
ADA CURB RAMP (CASE CH) FIELD INSPECTION CHECKLIST
No.
Requirement
Compliant
Photo
Remarks
For obstructions such as signposts, lighting standards,
power/telephone poles, guy-wires, or mail boxes in the
N/A
12
construction area, complete items 13-16.
Item 13-16
If no obstructions are located within the construction area
mark items 13-16 N/A.
Are objects with leading edges between 27” to 80” height,
Yes
No
13
protected by guardrails or other barriers less than 27” above
Yes
No
Yes
No
N/A
the finished surface?
For objects with leading edges between 27” to 80” height, is
Yes
No
14
horizontal protrusion less than 4” (4.5” for handrails) without
Yes
No
Yes
No
N/A
reducing the 48” minimum clear width requirement?
For objects mounted on single posts, that overhang the
Yes
No
15
sidewalk or curb ramp, are the overhangs less than 12” when
Yes
No
Yes
No
N/A
located between heights of 27” to 80”?
For objects mounted between posts, where the clear
Yes
No
distance between posts is greater than 12”, is the lowest
16
Yes
No
Yes
No
edge of such object less than 27” or greater than 80” above
N/A
the finished surface?
For curb ramp at a signalized intersection, complete items
17
Item 18-22
N/A
18-22. If not at signalized intersection mark items 18-22 N/A.
Yes
No
Is the pedestrian push button height within 38-42 inches from
18
Yes
No
Yes
No
the sidewalk surface or ground?
N/A
Yes
No
Is the pedestrian push button wheelchair accessible from
19
Yes
No
Yes
No
unobstructed forward reach?
N/A
Yes
No
Is the pedestrian push button wheelchair accessible from
20
Yes
No
Yes
No
unobstructed side reach?
N/A
Yes
No
For unobstructed side reach, is the pedestrian push button
21
Yes
No
Yes
No
within 10 inches of the edge of sidewalk?
N/A
Yes
No
Is the sidewalk slope and cross slope less than 1.7 percent
22
Yes
No
Yes
No
within the 48” x 48” area adjacent to pedestrian push button?
N/A
For a curb ramp located at an intersection with a crosswalk
23
Item 24-27
N/A
answer items 24-27. If no crosswalk mark items 24-27 N/A.
Remarks
Field inspection checklist completed 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.